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- OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date• (� Z�- �C� CONSTRUCTION <br /> Premise Address: 1f6S_/ �a�<„ �l o aC Well No. <br /> I <br /> SL'✓f-�,,�si- it.Gl p C : vh A n FP C..'�es��rs Total Depth <br /> ^ Screen Length / S <br /> Filter Pack / <br /> Bentonite Pellets <br /> Permit No. Grout <br /> Consultant1z1Z �2�a� , T�[t/utyal:Y, Fac Completion-Stove pipe Christie boxy <br /> Geologist <br /> If <br /> Auger O.D. <br /> Auger I.D. l <br /> SAMPLING --- <br /> Holding Temperature atk*up <br /> Method <br /> Screening Method <br /> AAOVE-GROUND CHRIST`f-BOX <br /> Tracking Sheet (y/n) COMPLETION COMPLETION <br /> Ground Surlacs <br /> SPOILS <br /> grout <br /> Storage Method ► _tt <br /> Contamination Noted - yes/no <br /> tt. <br /> Storage Location <br /> SPECIAL PERMIT INFO. o <br /> slotted .8WV7F` <br /> Distance to sewer line section —_ <br /> Domestic well on site - yes/no gmirel pack <br /> If yes, location & distance <br /> ft. <br /> GROUTING <br /> MATERIALS USED.: <br /> Depth to water <br /> / Casing type �) / r ���- <br /> Mix Ratios Blank /J ft. Screen ft. <br /> Installation Method Slot sized� c� 1) <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel ? <br /> Filter Pack type/size '�3 <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />