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t PAGE / OF I <br /> MONITORING WELL IN6ZAIr AXT—nN REPORT <br /> Date: J J //�� `� CONSTRUCTION <br /> Premise Add_e v[ !�. �� /�[ Well No. <br /> Ins_nector: Total Death <br /> Screen Length <br /> Filter Pack <br /> _q 7 Bentonite Pellets <br /> Permit No. 66v S 1 t - pp 7 Grout <br /> consultant Completion-Stove pipe/christie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> xtic4c up <br /> Holding Temperature <br /> Method ' <br /> Screening Method <br /> ABOVE-GRCUND C!-iRISTY-30X <br /> Tracking Sheet {y/n} CCW ETaN CCMPL'-TICN <br /> Ground Surface �----- <br /> S?OILS <br /> grout <br /> Storage Method __ft. <br /> Contamination Noted - yes/no <br /> ft. <br /> Storace Location <br /> _ a <br /> SPECIAL PERMIT INFO. c. <br /> 0 <br /> slc»ad = c <br /> Distance to sewer line '— <br /> Domestic well on site - ves/no <br /> gravol pack <br /> I ves, location & distance - <br /> i <br /> H <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water _ _ casing type <br /> Mix Ratios Blank ft. .Screen ft. <br /> Installation Method _ Slot size <br /> ,uanti_y Installed ( XzA -tS� 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 />