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• IWE Z--OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: Z •3 c/L / CONSTRUCTION <br /> Premise Address: Iy/O �//�� Well No. <br /> Inspector• Total Depth 9C2 _ <br /> Screen Length 3. 5 �Ff• <br /> Filter Pack <br /> Bentonite Pellets �o/•S SS.S <br /> Permit No. Z y Grout S <br /> Consultant L Complet' n-Stove i hristie box <br /> Geologist C° -"i•} <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING <br /> stldaup <br /> Holding Temperature <br /> Method T <br /> T <br /> Screening Method .. <br /> ABOVEGROUND CHRIS'TY-BOX <br /> Tracking Sheet (y n COMPLETION COMPLETION <br /> Orourd SuAece <br /> SPOILS OtaA <br /> Storage Method <br /> contamination Noted - yes n, <br /> Storage L cation <br /> _ e <br /> SPECIAL PERMIT INFO. <br /> 3 <br /> /�� dotted ` <br /> Distance to sewer line ✓� eeclan <br /> Domestic well on site - yest6or = yiavelpeck <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Z? Casing type- <br /> 4K—L— <br /> ype <br /> 4/ <br /> Blank ft. Screen Z ft. <br /> Mix Ratios <br /> Installation Method Slot size (22, <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 />