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` AGE f OF C <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> J <br /> Premise Addre (� ! <br /> Inspector' s Total Depth 7 U' <br /> Screen Length J <br /> Filter Pack <br /> _ G� t e/ Bentonite; ,Plellets <br /> Permit No. ��-j G f G8 Grout.r. a a✓P <br /> Consultant 6-2u cJ Completion=Stove pipe/christie box <br /> Geologist A�JIA <br /> Auger O.D. X3/0 " <br /> Auger I.D. <br /> �Z ` <br /> SAMPLING <br /> ofick-up <br /> Holding Temperature <br /> Method it C�7 <br /> Screening Method, <br /> ABOVE-GROUND <br /> ,-COMPLETION CHRISTY-BOX <br /> Tracking Sheet (y n) COMPLETION <br /> Ground Surface <br /> SPOILS <br /> grout <br /> Storage Method(�+ -5 � a<•�t iF <br /> Contamination Noted - ,e noft. <br /> Storage Locationn- <br /> __ft. <br /> V <br /> SPECIAL PERMIT INFO. e <br /> ,. / slotted c <br /> Distance to sewer line section <br /> Domestic well on site - ye _ Pa <br /> If yes, location & distance <br /> ft. <br /> GROUTING <br /> MATERIALS USED: <br /> A-11A <br /> Depth to water Casing type. <br /> Mix Ratios Blank ft. Screen ft. <br /> Installation Method Slot size <br /> Quantity Installed 4 f 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 />