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rnt3E_�0F J <br /> MONITORING WELL INSTALLATION REPORT <br /> Date• -- � ! /� CONSTRUCTION <br /> Premise Address: �d��• �nWOIJ Well No. <br /> Inspector: 2af/� Total Depth <br /> Screen Length <br /> Filter Pack <br /> Bentonite Pellets ..�-.X�• S <br /> Permit No. w" 3 5 Grout / <br /> Consultant �✓� Completion-Stove pipe Christie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING �-' <br /> stick-up <br /> Holding Temperature <br /> Method �n��� S)2�0k, <br /> Screening Method <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet FOE- <br /> n COMPLETION COMPLETION <br /> Grourd SuAeee <br /> �5�s " ��✓aipppm �9� Q� <br /> Storage Method ��et <br /> Contamination Notedo5'-f n. <br /> Storage Location <br /> b5 � 13 � <br /> m <br /> _ o <br /> SPECIAL PERMIT INFO. <br /> o I`l J D <br /> Zai slotted = <br /> Distance to sewer line tet4on = <br /> Domestic well on site - /no = gravel pack <br /> If yes, locat'on / distan e - <br /> o �0 7�✓P7� <br /> n. = tL <br /> GROUTING <br /> MATERIALS USED: <br /> Pyc- <br /> Depth to wat r Casing t e ' <br /> Mix Ratios _ Blanks ft. Screen '3^=� ft. <br /> Installation Method Slot size O Z <br /> Bags cement <br /> Quantity Installed Ba 4 <br /> 111r Buckets bentonite 3 <br /> 1 lv Bag s(-?a-n3i gravel <br /> Filte ack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />