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PAGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> I <br /> Date: L d CONSTRUCTION <br /> Premise A e s: Well No. <br /> Inspector: Total Depth <br /> Screen Length 61— <br /> Filter Pack <br /> Bentonite Pellets —(v <br /> r Permit No. \ Grout <br /> Consultant Completion-Stove pie h�istie box <br /> Geologist <br /> Auger O.B. <br /> Auger I.D. <br /> SAMPLING <br /> Melding Temre <br /> perafICA, - 6 <br /> Method �h � <br /> N Screening Method <br /> A$OY -GROUND CHRISTY-BOX <br /> Tracking Shee y n COMPLETION <br /> G=nd Surface <br /> SPOILS <br /> proof <br /> Storage Method�� <br /> Contamination Noted - ye no ���lllft <br /> ft. <br /> Storage Location ^!�. <br /> A <br /> m <br /> 4 SPECIAL PERMIT INFO. c <br /> i o <br /> � alottad = � <br /> Distance to sewer line section $ <br /> Domestic well on site - ye no gr*vWpack <br /> If yes, location & distance <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type <br /> Mix Ratios Blank /5- ft. Screen ft. <br /> Installation Method . Slot size C9 �1 172 <br /> I Quantity Installed Bags cement J <br /> Buckets bentonite Alipix <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed 'Time Per Site <br /> i <br /> 4 <br /> Date Permit Finalized <br />