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i *AGE �OF J <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: / O� / / y I CONSTRUCTION <br /> Premise Address: 4i � Well No. IM U I <br /> z <br /> Inspector: Total Depth -73 <br /> q i Screen Length 3 —s3 <br /> Filter Pack 73- 90' S <br /> Bentonite Pellets <br /> Permit No. �/ Grout 6• _ <br /> Consultant 2d t Completio tove pipe chtistie box <br /> Geologist C' s/ <br /> Auger O.D. �r-�� <br /> Auger I.D. <br /> SAMPLING -- <br /> atlek-up <br /> Holding Temperature ICe <br /> Method_ T/1� <br /> Screening Method <br /> ABOVE-GRODND CHRISIY-BOX <br /> Tracking Sheet ( / COMPLETbN COMPLETION <br /> ®Ground Surface <br /> SPOILS <br /> proal <br /> Storage Method <br /> Contamination Noted - yes no ft <br /> Storage Location — <br /> �v� <br /> — m <br /> a <br /> SPECIAL PERMIT INFO. = o <br /> slooad <br /> Distance to sewer line < auction = <br /> Domestic well on site - yes o _ pravWpack <br /> If yes, location & dish,'I-A. <br /> /IIII <br /> GROUTING <br /> MATERIALS USED: I/ <br /> Depth to water Casing type ✓ <br /> Mix Ratios Blank ft. Screen eft. <br /> Installation Method t <br /> Slot size O <br /> quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size ? Z- <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />