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i <br /> I� <br /> ii <br /> MONITORING WELL INSVIMATION REPORT <br /> Date: C� / 7 ONSTRUCTION <br /> Premise Address:4 ,5-, <br /> s `/ <br /> Inspector: r otal Depth__- eo <br /> Green Length r'M Z0= f70 <br /> filter PackF 20 = "76 <br /> entonite Pellets ,-I, <br /> Permit No. �i !� o rout Z•�p" 7e` s�s.ec,�G� <br /> Consultant :!ompletion-stove pipe/ hrietie bo <br /> Geologist <br /> uger O.D.--- <br /> I <br /> .D. �. Z <br /> uger I.D. k;-C,- 2 <br /> SAMPLING ! - - <br /> �i <br /> Holding Temperature <br /> sUd«-up <br /> Method CAus <br /> Screening Method 0 ✓rpt <br /> -GROUND <br /> Tracking Sheet �/n) COMPLETION CHRISTY-BOX <br /> COMPLETION <br /> Ground S fwo ��•■ <br /> SPOILS <br /> {' grout <br /> Storage Method .r <br /> Contamination Noted - ye <br /> s • <br /> Storage Location I: fi• <br /> A <br /> SPECIAL PERMIT INFO. I: <br /> Distance to eewer •line sfedon <br /> Domestic .well on site yes no <br /> gMVd <br /> If yes, location & distance - = P <br /> GROUTING <br /> MATIERIALS USED: <br /> Depth to water '; Casing type Zl�YC 5C1 y0 <br /> Mix Ratios "< Blank --N ft. Screen . r ft. <br /> Installation Method ' Slot size Z c _ s <br /> Quantity Installed !. Bags cement <br /> ` Buckets bentonite____ <br /> Bags sa d gravel <br /> Filter Pack type/size Z �Z <br /> i <br /> f <br /> �f <br /> !i <br /> i� <br />