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r 3E OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: / - / _ CONSTRUCTION <br /> Premise Addres : / Ay' u �• Well No. <br /> Inspector• Total Depth L7. 10 <br /> Screen Length - 3O <br /> Filter Pack <br /> Bentonite Pellets <br /> Permit No. Grout <br /> Consultant Completion-Stove pipe/ hristie box <br /> Geologist <br /> Auger O.D. /D <br /> Auger I.D. <br /> SAMPLING <br /> Holding Temperature <br /> stk*-up <br /> Method (Tk <br /> Screening Method KID <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) 0OWFLE7ION OMP <br /> SPOILS Ground Surface <br /> Grout <br /> Storage Method <br /> Contamination Noted - yes/no n. <br /> Storage Location . <br /> a <br /> SPECIAL PERMIT INFO. c <br /> o <br /> slotted _ c <br /> Distance to sewer line section •� <br /> Domestic well on site - yes/no <br /> gravel Pa(* <br /> If yes, location & distance - <br /> ft. ft• <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing t pe <br /> Mix Ratios Blank ft. Screen Z r3 ft. <br /> Installation Method Slot size - 02- <br /> Quantity <br /> OZQuantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site t U <br /> Date Permit Finalized <br />