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`,lAGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: Z�I CONSTRUCTION <br /> Premise Address: ✓hlNl. �-N Well No. <br /> Inspector: Total Depth 3 <br /> Screen Length <br /> Filter Pack -v/ _2 •s _� <br /> Bentonite Pellets _ 20•S S <br /> Permit No. C/D 3 Dgg Grout_ -/k. S -30 �- <br /> Consultant....i1 Completion-Stove pipe christie box <br /> Geologist <br /> Auger O.D. . Z <br /> Auger I.D. 6 - ZJ <br /> SAMPLING <br /> Holding Temperature 4'0 stick up <br /> Method /Sc •c�- ICO- <br /> Screening Method <br /> ABOVE•GROIIND CHRISTY-BOX <br /> Tracking Sheet (y/n) COMPLETION COMPLETION <br /> Ground Surface <br /> SPOILS <br /> proal <br /> Storage Method 611 �'�'�`� �Y,ljr <br /> ft. <br /> Contamination Noted - yes / -Zp S <br /> h. <br /> Storage Location <br /> �,J Sri - <br /> SPECIAL PERMIT INFO. = u <br /> Waned = $ <br /> Distance to sewer line Wecllon <br /> Domestic well on site - yes/� = OmiWpack <br /> If yes, location & distance - .- <br /> r <br /> GROUTING <br /> MATERIALS USED: <br /> / u <br /> Depth to water Casing type 5cg- Ale- <br /> mix <br /> lCMix Ratios Blank2-1 ft. Screen / 0 ' ft. <br /> Installation Method Slot size 0• D/O <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel 'f— <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />