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Y <br /> PAGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date:__ 2'Z� U _ CONSTRUCTION <br /> Premise Address: 61411 jz F�- Well No. 12 <br /> —00,+&77.77 7,e e,5 Ht a n l P cy <br /> Ir�ers��ere Total Depth � <br /> L+Gr[ -2. Screen Length <br /> Filter Pack <br /> 1�- <br /> Bentonite Pellets---,;).-/ <br /> Permit No. �� r ��f Grout <br /> Consultant 72srr�.,t►�_ �2l�x�L�Y, ��t_ Completion-Stove pipe Christie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING <br /> Holding Temperature stick-up <br /> Method rV <br /> Screening Method <br /> ABOVE-GROUND CHRIS1Y-BOX <br /> Tracking Sheet (y/n) COMPLETION COMPLETION <br /> Ground Surtaca <br /> SPOILS <br /> grout <br /> Storage Method <br /> Contamination Noted - yes/no n• <br /> ft.Storage Location <br /> p <br /> SPECIAL PERMIT INFO. <br /> 0 <br /> aloud <br /> Distance to sewer line "Coon <br /> Domestic well on site - yes/no gmvw P <br /> ack <br /> If yes, location & distance - <br /> GROUTING ' <br /> MATERIALS USED: <br /> �i <br /> Depth to water Casing type„- 2 <br /> a <br /> Mix Ratios Blank /L-5�2 ft. Screen 15 ft. <br /> Installation Method Slot size 47.0 -2— <br /> Quantity <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/grave l _2 <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />