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� . <br /> • ` 'AGE OFT <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: �� N,, CONSTRUCTION <br /> Premise Address:/3U� t L [ i Well No. IN JAI 1A) <br /> Inspector: ,C��C � _ Total Depth Q' 7S� <br /> Screen Length `c'_S' <br /> Filter Pack.-Src^,k <br /> Bentonite Pellet�utS <br /> Permit No. Grout --44 �._,A) <br /> Consultant Completion-Stave pie/chxstie b x ' <br /> Geologist 4/y , <br /> Auger O.D. { <br /> Auger I.D._ <br /> SAMPLING <br /> Holding Temperature 7 w $**-up <br /> Method 13A.«4�0 Tom .- 4 <br /> Screening Method l/� .. <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y n) COWLETION COMPLETION <br /> Ground Surf we <br /> SPOILS <br /> grout <br /> Storage Method &O&CL <br /> Contamination Noted - yes no <br /> Storage Location46 <br /> f51n � b ft' <br /> A <br /> m I <br /> SPECIAL PERMIT INFO. <br /> 6104od C <br /> Distance to sewer linewcdon <br /> Domestic well on site - pa*e /no _ <br /> If yea, location & dist&e <br /> [W <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water l J Casing -t e vii Z.1 f <br /> Mix Ratios A-t Blank ft. Screen ft. <br /> Installation Method slot size .OZ v <br /> Quantity Installed Gf Bags cement <br /> Buckets bentonite / <br /> Bags sand/gravels( <br /> Filter Pack type/size <br /> Total Balled Time Per Site <br /> Date Permit Finalized <br />