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`..� AGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: // - CONSTRUCTION <br /> Premise Address: x(00 N ` 014*1 Well No. � <br /> inspector: Total Depth r <br /> 'rj.• Lf3 y� Screen Length <br /> Filter Pack -- la" <br /> t� Bentonite Pellets <br /> Permit No. ^ 2� Grout - 4G --'t► 4- <br /> Consultant— Completion-Stove pipe/ch i tiebox <br /> Geologist ef1i„ / l <br /> Auger O.D. �'2"'S <br /> Auger I.D. Ap, <br /> SAMPLING <br /> •tr stick-up <br /> Holding Temperature fy, <br /> Method K,;- i <br /> Screening MEtthod <br /> 4-Afi/`-- ABOVE-GROUND <br /> Tracking Sheet ) COMPLETION COMPLETION <br /> Ground Surface <br /> SPOILS <br /> grout <br /> Storage Method �� � <br /> tt. <br /> Contamination Noted - yes/r3--) ft. <br /> Storage Location 46 <br /> QKJ — <br /> 'CD <br /> _ o <br /> SPECIAL PERMIT INFO. c <br /> 0 <br /> slotted ._ c <br /> Distance to sewer line wcdon <br /> Domestic well on site - yes/no = gnveIPack <br /> If yes, location & distance - <br /> _._ft. ft. <br /> GROUTING <br /> MATERIALS USED: ' / <br /> Depth to water t0 7 / Casing t pe 4�-�T �V Al <br /> Mix Ratios Blank ft. Screen�_ft. <br /> Installation Method Slot size 0. d� <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 />