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9AGE-OF <br /> MONITORING WELL INSTALLATION REPORT <br /> CONSTRUCTION <br /> Premise Address: Well No. <br /> Inspector: Total Depth <br /> Screen Length <br /> Filter Packa <br /> Bentonite Pellets ""''�c <br /> Permit No. Grout <br /> Consultant Completion-Stove pipe/christie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING ------ ____-_ <br /> Holding Temperature etk*up <br /> Method <br /> Screening Method <br /> ABOVE-GROUND CHRISTY 80X <br /> Tracking Sheet (y/n) CONPLETION COMPLETION <br /> Ground Surface <br /> SPOILS <br /> proal <br /> Storage Method <br /> Contamination Noted - yes/no n <br /> Storage Location n• ft. <br /> _" •ir <br /> w <br /> SPECIAL PERMIT INFO. — c <br /> 0 <br /> Distance to sewer line mon — $ <br /> Domestic well on site - yes/no _ 9P <br /> ack <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> 1/ <br /> Depth to water O Casing type <br /> Mix Ratios Blank ft. Screen 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 /> DaLe Permit Finalized <br />