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AGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: i l CONSTRUCTION <br /> f 1.` l iJ1J <br /> Premise Address: " V'`��1� well No.;} t . <br /> Inspector: ZIA Total Depth r <br /> i Screen Length �S <br /> Filter Pack <br /> Bentonite Pellets-- <br /> �- <br /> Permit No. -l 4 ���-fit__ __ Grout �_ <br /> Consultant- .S Q Y completion--Stove. pipe. ristie box <br /> ------------------------ <br /> Geologist Z.dr-p_ 4h..n, c n <br /> Auger 4.D. � n <br /> Auger I.D. <br /> SAMPLING - <br /> Holding Temperature., stick�p <br /> Method 6tw_ ur <br /> Screening Method_ :CID <br /> ABOVE-GROUND. CHRISTY-BOX <br /> Tracking Sheet,- ,/n} CO�LETION COMPLETION, <br /> Ground Surface <br /> SPOILS <br /> grout <br /> I Storage Method �S <br /> Contamination Noted - yes o � <br /> Storage Location 6=0 WS n' <br /> !t. <br /> b <br /> - O <br /> SPECIAL PERMIT INFO. <br /> ! dotwd = E <br /> Distance to sewer line "cdcn — <br /> Domestic well on site - yes <br /> If yes, location. & distance ;c' _ 9MV*1 <br /> f� a <br /> GROUTING <br /> MATERIALS USED: <br /> Olr <br /> Depth to water `t� Casing t pe '9 ! U C S � 1� <br /> .Mix Ratios (o 'ham 56-fvy Blank ft. Screen. _ �S_ft. <br /> Installation Slott size <br /> Quantity Installed U- !00 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 />