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.GE 2- OF J <br /> MONITORING WELL INSTALLATION REPORT <br /> Date : u /c CONSTRUCTION <br /> Premise Address : �L/' Well No . <br /> Inspector • o?� SDF/'e*+On� Total Depth 70 <br /> �. Screen Length <br /> Filter Pack <br /> C, Bentonite Pellets H7 - �'h% Si <br /> Permit No . D' � / Grout <br /> Consultant lt/ Cin- O GSOV, C CS Completion- Stove pipe / ristis box <br /> Geologist L1411LA �:;04 <br /> Auger O . D . <br /> Auger I . D . <br /> SAMPLING <br /> sddc-up <br /> Holding Tempera/are � - <br /> Method {. ) l ID <br /> Screening Method 74 <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet ( y COMPLETION COMPLETION <br /> ® Ground Surface <br /> SPOILS <br /> proal <br /> Storage Method L) 1 <br /> Contamination Noted - yes no _.Z.� ft. <br /> Storage Location ft <br /> m <br /> SPECIAL PERMIT INFO . = o <br /> slotted _ <br /> Distance to sewer line section <br /> Domestic we on site — yes <br /> gravel pack <br /> If yes , location & distance <br /> fte = ft. <br /> GROUTING <br /> MATERIALS USED : <br /> Depth to water F� � casing type <br /> Mix Ratios �(� / Blank ft . Screen ft . <br /> 0 Z <br /> Installation Method 4-rtmM4t Slot size I <br /> Quantity Installed Bags cement �Z <br /> Buckets bentonite <br /> Bags sand / gravel 7, 5� ' <br /> Filter Pack type / size 2t�- 3 <br /> Total Billed Time Per Site <br />'r <br /> Date Permit Finalized <br />