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MONITORING WELL INSTALLATION REPORT <br /> Date• / Z// // 7 CONSTRUCTION .,�1 <br /> Premise Address: ma'_'fr T�^�r Well No. 'V` <br /> Inspecj Total Depth a CJ <br /> Screen Length �' s <br /> Filter Pack QO- 3,5 <br /> c Bentonite Pellets 3 , 5- 2- 5, <br /> Permit No. ` / Grout 2 5 - 'l <br /> Consultant � `� `T- Completion-Stove piRalchristie box <br /> Geologist Qo..,'A 'A G+ <br /> , Auger O.D. 19W , �s <br /> Auger I.D. 3 • Z S <br /> SAMPLING <br /> stick-up <br /> Holding Temperature <br /> Method T <br /> T <br /> Screening Method <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y n comPLETION COMPLETION <br /> Ground Surface <br /> SPOILS <br /> nn grout <br /> Storage Method JxfV 4.0 <br /> Contamination Noted - yes/(!V ft. <br /> Storage Locat'on ©4 <br /> SPECIAL PERMIT INFO. <br /> 0 <br /> slotted _ <br /> Distance to sewer line section <br /> Domestic well on site - ye no — gmel pack <br /> k. <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type <br /> Mix Ratios Blank S ft. Screen /S ft. <br /> Installation Method Slot size <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 />