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IS/ �1GE OF <br /> MONITORING WELL INSTALLATION REPORT CIVIC V When{-r <br /> p�zsttc SK�i l�ttS�' <br /> Date: �"' J�l�" V �II/�I�'�,,I� CONSTRUCTIO <br /> :P, <br /> N 1. <br /> Premise Address: L 1��C�tln Well No. M W tq I <br /> Inspector• :t Total Depth ':kO <br /> Screen Length 14 - &-I <br /> Filter Pack 14 r <br /> Bentonite Pellets 2-r <br /> Permit No. I ' I Grout O G, ID- <br /> Consultant (jMu-n wJO,4 n o: 1. Completion-Stove. pipe/ ristie box <br /> Geologist E" '-� nnlS I��-y—�Q,(I n �',� <br /> Auger O,.D. l rJ <br /> Auger I.D. <br /> SAMPLING W(`2�+ d O.•. 6 4,C- <br /> "-C4 --Arn?L6 <br /> 4, -"-C4Arn?L6 <br /> Holding Temperature r�rUrEl �j`MCM5'WeA-ZZ-0 **X-up <br /> Method hIU2 IU - baf, t f4 IffT <br /> Ilc.f <br /> Screening Method qKQ 4W- T <br /> • ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet &)n) lSv"�' COMPLETION <br /> h yef- Qgm� "--SW COMPLETION <br /> SPOILS �OrOund Sudan + � <br /> proal <br /> Storage Mettiohod N `f <br /> Contaminan Noted - yea no n' <br /> Storage Location - n' <br /> 0i <br /> = m <br /> _ e <br /> SPECIAL PERMIT INFO. _ <br /> o <br /> Distance to sewer line � auction —_ <br /> Domestic well on site - yes/D <br /> If yes, location & distance - <br /> GROUTING <br /> G MATERIALS USED: <br /> Depth to water .J! ce �`'� Casing type PVc <br /> Mix Ratios �•�iNC�. rnI Ifil[r�� Blank ft. Screen 14 ft. <br /> Installation Method UW1 t Slot size () <br /> Quantity Installed t Bags cement Iq bA`g Fbrr'&Fdceh-&� <br /> Buckets bentonite ;�<P _bu <br /> Bags sand/gravel 3 <br /> /4 krl- <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />