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P&,�OF J <br /> v <br /> MONITORING WELL INSTALLATION REPORT <br /> Date.• % -� /� CONSTRUCTION <br /> Premise Address: �d�S. �cR7pnr� Well No. <br /> Inspector: �af/� Total Depth - - <br /> Screen Length fS�- <br /> Filter Pack 6 S3 <br /> Bentonite Pellets <br /> Permit No. Grout / <br /> Consultant Completion-Stove pipe hristie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING <br /> stick-up <br /> Holding Temperature <br /> Methodwin T <br /> T <br /> Screening Method . . <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet ( n COMPLETION COMPLETION <br /> t <br /> softs nd Surface <br /> 15�t Grou7fi�l�a�°p1'n` ' <br /> 1/ �9� r1� proal <br /> Storage Method riG <br /> Contamination Noted -�e no <br /> Storage Location _ _ g, _ 46 <br /> j5 ell, <br /> .y� <br /> _ m <br /> SPECIAL PERMIT INFO. <br /> slotted = 8 <br /> Distance to sewer line Zai section _ <br /> Domestic well on site - /no = GnvWpack <br /> If yes, locat'on � distan re - <br /> n. = n. <br /> GROUTING <br /> MATERIALS USED: <br /> PVC- <br /> Depth <br /> to war Casing ,ttvpe ' <br /> Mix Ratios t Blank J-S ft. Screen�_ft. <br /> Installation Method Slot size n Z <br /> Baas cement r <br /> Quantity Installed Ba 4 <br /> IOU <br /> Buckets bentonite l <br /> Bags an gravel <br /> Filte ack type/size ;j5i� 2: <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />