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P <br /> I <br /> E OF <br /> MONITORING WELL. INSTALLATION REPORT <br /> i <br /> Date• l /O/ _ CONSTRUCTION <br /> 03 ' <br /> Premise Addre s: �`� Well No.- <br /> inspector: Total Depth <br /> Screen Length.?-a <br /> Filter Pack 5A—.*t <br /> Bentonite Pelletso��i <br /> Permit No. Grout Cp.�,� _ <br /> Consultant /� ld� Completion-Stove pip Christie b x <br /> Geologist <br /> Auger O.D. _ <br /> Auger I.D. q " - <br /> SAMPLING - -- — <br /> (f <br /> Holding Temperature stick-up <br /> Method 8_A-e•� <br /> Screening Method <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet( <br /> hee (y/ ) COMPLETION COMPLETION <br /> Ground Surfaces ; <br /> SPOILS <br /> grout <br /> Storage Method <br /> Contamination Noted yes no j <br /> Storage Location 01- <br /> CD <br /> h <br /> a <br /> m <br /> SPECIAL PERMIT INFO. c <br /> ' dottod c <br /> Distance to sewer linesoon <br /> Domestic well on site - yea Un = gr*�Wpack <br /> If yes, location & distance <br /> GROUTING <br /> MATERIALS USED: I <br /> Depth to water Z Casing type // <br /> Mix Ratios lL��o�r P�-t..�/�'� Blank ft. Screen C) ft. k <br /> Installation Methodi'u cam - Slot size a�U <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel 3 Sb-� <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />