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• WE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: -3/ S / CONSTRUCTION <br /> Premise Address: / • y ' Well No. ��✓ / V S <br /> Inspector: Total Depth i�o <br /> Screen Length 9C.— k5- <br /> Filter Pack /15'C� -_76- <br /> Bentonite <br /> 7GBentonite Pellets 76 - 73 <br /> Permit No. 7 U 'S/L Grout 7 -21 - <br /> ConsultantJ, c A, Completion-Stove pipe c ris <br /> Geologist ion �_/7� rn-� <br /> Auger O.D. 1 <br /> Auger I.D. r,07--. <br /> SAMPLING - SuM� ezccr'p6 ,jG✓e- <br /> s up <br /> Holding Temperature <br /> MethodT <br /> T <br /> Screening Method ... <br /> ABOVEGROUND CHRISTY-Box <br /> Tracking Sheet (y/n) COMPLETION COMPLETION <br /> (around Surface <br /> SPOILS <br /> prari <br /> Storage Method <br /> Contamination Noted - yes/no ft. <br /> Storage Location ft. <br /> _ o <br /> p <br /> _ 0 <br /> Y <br /> SPECIAL PERMIT INFO. <br /> 0 <br /> slotted _ $ <br /> Distance to sewer line ►ecton <br /> Domestic well on site - yes/no = gntvW pack <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water — Casing type <br /> Mix Ratios SAH+ CSS _ Blank ft. Screen _ft. <br /> Installation Method Slot size <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />