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GE 1 OF� <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: ( J ! � CONSTRUCTION <br /> Premise Address: ��+/T Well No. <br /> Inspector, Total Depth Y6 <br /> Screen Length <br /> Filter Pack %x--33 <br /> �j Bentonite Pellets t <br /> Permit No. / T Grout 3 - <br /> Consultant ee ' vdl Completion-stove pip Christie box <br /> Geologist "9r-/C 62 r"I <br /> Auger O.D. <br /> Auger I.D. 1r `P <br /> SA24PLING <br /> Holding Temperature �� $**-up <br /> Method sp i 3- SA�-an <br /> Screening Method <br /> ABOVEGROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) OOMPLETION COMPLETION <br /> Ground Surface <br /> SPOILS <br /> grout <br /> storage Method 69/7 BSG <br /> Contamination Noted - ye -.-- <br /> Storage Locations l? S0l� T~ ` <br /> 0 <br /> SPECIAL PERMIT INFO. s c <br /> t o <br /> clotted <br /> Distance to sewer line aocdon <br /> Domestic well on site - yegravW pack <br /> n <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water _ Casing type <br /> Mix Ratios Blanka�2 � it. Screen /U ft. <br /> Installation Method Slot size © 2- <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 /> pml jM/ <br /> f <br />