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,i PAG...e�z- OF J <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: zy- 9! CONSTRUCTION <br /> Premise Address:/°S° 5 KJ.!Gn/oitO Well No. <br /> inspector• Total Depth <br /> „ f Screen L agth .'D <br /> Filter Pack - �• <br /> Bentonite Pellets hl.a - 49• <br /> Permit No. �O ' 33 /5' Grout APA4 JAKJ&L <br /> Consultant G✓-e71�s1 Completion-Stove pipes/chrstie o5cD <br /> Geologist <br /> Auger O.D. /U ( <br /> Auger I.D. it <br /> SAMPLING <br /> etlek up <br /> Holding TemperatureI ff I <br /> Method <br /> Screening Method <br /> 51 o ABOVE.GROIJND CHRISTY-BOX <br /> Tracking Sh t (yt9 OO1"PLETION COMPLETION <br /> 250ZZ --Ground Surface <br /> OILS <br /> proal <br /> Storage Method On <br /> Contamination Noted - es no ft <br /> Storage Location <br /> d /_ <br /> o 5 //Pc✓ a/CU DlR l�f C/�6�✓Si3 _ <br /> m <br /> —twT <br /> m <br /> SPECIAL PERMIT INFO. o <br /> slotted = c <br /> Distance to sewer line taction <br /> Domestic well on site - yQs/no = gravel pack <br /> If yes, location & distance - - <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to wate 7� Casing type PUC_ `7�� <br /> Mix Ratios 'Vl Blank ft. Screen ft. <br /> Installation Metho 1� Slot size •�Z_ <br /> Quantity Installed 9a^ Bags cement <br /> Buckets bentonite <br /> `7QifJf� igµX{ Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />