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AGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: —( CONSTRUCTION <br /> S <br /> Premise Address: 3 S3 5 Well No. <br /> InspecctgLr Total Depth_, <br /> �• Q Screen Length l00 - 75' 7 <br /> Filter PackICGIC�' - 7 C <br /> -� [/�/ Bentonite Pellets d' <br /> Permit No. d Y 6 Grout G 7 — <br /> Consultant----7s 7 Completion-Stove pip christie box �- o <br /> Geologist a G/a <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING ---. <br /> Holding Temperature stick-up <br /> Method <br /> Screening Method <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) COMPLETION <br /> COMPLETION <br /> SPOILS --t�aurd Surface +-- <br /> kd grout <br /> Storage Method �� �v c f i <br /> Contamination Noted - yes/no n <br /> Storage Location <br /> n. <br /> O <br /> SPECIAL PERMIT INFO. <br /> �V / <br /> Distance to sewer line V WoodNe6cn — 8 <br /> Domestic well on site - yea no <br /> ta <br /> e <br /> If yes, location & dis <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to waterCasing type Iy <br /> Mix Ratios Blank ft. Screen ft. <br /> Installation Method Slot size.6) 2 <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size Z Z <br /> Total Billed Time Per Site <br /> Date Permit Finalized ���(� <br />