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%E OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: I CONSTRUCTION <br /> Premise Add r s Well No. <br /> Inspector- Total Depth <br /> Screen Length �y ' <br /> r � <br /> Filter Pack_ ^� <br /> Bentonite Pellets ZZ- 5 2-115 <br /> Permit No. v Grout 0 ZZ ,I- <br /> Consultant CompletiWon&�v�e pipe Christie boxGeologistAuger O.D. <br /> Auger I.D. <br /> SAMPLING <br /> i <br /> Holding erature <br /> D sildc-up <br /> Method <br /> Screening Method ... <br /> ABOVE-GROUND CHRI X <br /> Tracking Sheety n) COWFLETION PLETION <br /> Ground Surface —+-- <br /> SPOILS <br /> grout <br /> Storage MethodIZA— <br /> it. <br /> Contamination Noted - yeq/no n, <br /> Storage Location <br /> a <br /> SPECIAL PERMIT INFO. / <br /> o <br /> Clotted � <br /> Distance to sewer line k,,Ak7 section <br /> Domestic well on site - yes/Vo = gra pack <br /> If yes, location & distance <br /> +._.ft. = L---ft. <br /> GROUTING <br /> MATERIALS USED- <br /> Depth to water 3�0•� Casing type <br /> Mix Ratios Blank 19 55 ft. Screen � ft- <br /> Installation Method Slot size .0 <br /> Quantity Installed Bags cement <br /> Buckets bentonite_ <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />