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Q(;E__LOF <br /> MONITORING WELL INSTALLATION REPORT <br /> 1 <br /> Date,. �/ /tl S d CONSTRUCTION ti <br /> r <br /> i <br /> Premise Address:e,-Z/r- u. (J5 well No- SK r S <br /> Inspector•�m�E-t-L _ Total Depth �S� <br /> Screen Length ti1"1 <br /> .1 Filter Pac 4 <br /> Bentonite Pellets <br /> Permit No. �U Grout n .l Cenwti ' _ <br /> Consultant �Z;Z__1 Completion--Stove pipe/christie box <br /> Geologist c..- <br /> Auger O.D. <br /> Auger I.D.3y-Gf <br /> SAMPLING ,! - --- — <br /> Holding Temperature <br /> Method RA &4-. � <br /> Screening MethodCZ)9),- <br /> ABOVE CHR157Y-SOX <br /> Tracking Sheet (y ) OOMPLE ION COMPLETION <br /> j3 G=nd Sur(=.Q <br /> SPOILS <br /> grout <br /> Storage Method <br /> Contamination Noted - yes/ <br /> it. <br /> Storage Location • <br /> SPECIAL PERMIT INFO. a <br /> cloned <br /> Distance to sewer line ✓ taction <br /> Domestic well on site - yes nab lavelPack <br /> If yeg, location & distance <br /> I <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water �S Casing type <br />: . Mix Ratios Blank ft. Screen ft. <br /> Installation Method Slot size <br /> Quantity Installed 3 3' Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total.1Billed Time Per Site <br /> Date Permit Finalized/ �6 <br />