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GE / OF q <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: L//�7// CONSTRUCTION <br /> --r <br /> Premise Addres : � C Well No. l� <br /> Inspector: Total Depth 140 <br /> -Screen Length <br /> Filter Pack St"" 2 I y <br /> Bentonite Pellets <br /> Permit No. / O � Grout <br /> Consultant T Completion-Stove p,pe chxistie bo <br /> Geologist <br /> Auger O.D. /Q <br /> Auger I.D. Gw t' <br /> SAMPLING <br /> Holding Temperature <br /> Method 13A,4n- 7_JLL-, <br /> Screening Method T>/6 T <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet ( n} COMPLETION COMPLETION <br /> Ground Surface <br /> SPOILS <br /> proof <br /> Storage Method <br /> it. <br /> Contamination Noted - yes n <br /> Storage Location 01ov - ft. <br /> SPECIAL PERMIT INFO. = <br /> slotted S <br /> Distance to sewer line GSO section = <br /> Domestic well on site - ye /no = gn% l <br /> ack <br /> If yes, location & distance - <br /> =tt. — 30 n. <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Zy Casing type �/: q u <br /> Mix RatiosCp�c,.�,✓ri'.�Ql�tt� Blank /.57 ft. Screen ( ft. <br /> Installation Method a eP Slot -size :dI <br /> Quantity Installed Bags cement_ S <br /> Buckets bentoni e �� f <br /> Bags sand/gravel'' �f <br /> Filter Pack type/size S� : <br /> i j <br /> Total Billed 'Time Per Site <br /> i <br /> Date Permit Finalized <br /> � ti'k o <br /> mvv- I �� <br />