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• &AGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date• v CONSTRUCTION <br /> Premise Address: / / G� .' Well No. o,�3 I � <br /> Inspector: Total Depth `r5 / <br /> Screen Length v--5-- 35' <br /> Filter Pack y5' /, <br /> Bentonite Pellets 1-2- <br /> Permit <br /> -2-Permit No. Grout C <br /> Consultant—� Completion Stove pipe christie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING - - ---- <br /> Holding Temperature stick P <br /> Method <br /> Screening Method <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) COMPLETION <br /> COMPLETION <br /> Ground Surface <br /> SPOILS <br /> grout <br /> Storage Method <br /> Contamination Noted - yes/no : <br /> Storage Location <br /> SPECIAL PERMIT INFO. <br /> Distance to sewer line slotted <br /> section <br /> Domestic well on site - yes/no = gravW P <br /> ack <br /> If yes, location & distance - '- <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water 3 b / Casing type C- <br /> Mix Ratios Blank _35 ft. Screen / D 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 />