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AGE�OF I <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: �7U /��%� Well No. �t✓ <br /> Inspect Total Depth <br /> Wim/ Screen Length - <br /> Filter Pack - <br /> �/_ Bentonite Pellets_ A <br /> Permit No. Grout / <br /> Consultant v"' Completion-StovepipZ c ris ie box <br /> Geologist t.✓L aco <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING - - <br /> Holding Temperature /rGT� atkk-�rP <br /> Method <br /> r7 f <br /> Screening Method Im <br /> R <br /> /►ROVE-GROUND CHRISTI-BOX <br /> Tracking Sheet (yam COMPLETION COMPLETION <br /> Ground Suriact <br /> SPOILS <br /> proof <br /> Storage Method f <br /> Contamination Noted <br /> Storage Location ft. <br /> SPECIAL PERMIT INFO. o <br /> slottad <br /> Distance to sewer line sacdon —_ <br /> Domestic well on site - yes = 9MP <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing� ty e <br /> Mix Ratios xBlank ft. Screen U ft. <br /> Installation Method/ � Slot size Z� <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel__ <br /> Filter Pack type/size 7:) <br /> Total Billed Time Per Site <br /> s�S� es <br /> Date Permit Finalized <br />