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'AGB / OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date : CONSTRUCTION <br /> L r /' <br /> Premise Address : ,��<-5s- ) ��r'�N/✓��7 Well No . <br /> Inspector : Total Depth <br /> Screen Length T 'f�9 ` GO <br /> Filter Pack -� ' S 7 <br /> Bentonite Pellets S7 <br /> Permit No . /` <-� � � S Grout <br /> Consultant �4%f/� / `��� � \ <br /> /r<'� Completion-Stove pipe �christ ie�ox__ ) <br /> Geologist /'7`, cam ° /� P <br /> Auger O . D . <br /> Auger I . D . - <br /> SAMPLING --- - -- - - - - - - <br /> Holding Temperature stldo-up <br /> Method :r�Orl �' <br /> Screening Method <br /> ABOVEGROUND CHRISTY-BOX <br /> Tracking Sheet ( y( rr)) COMPLETION COMPLETION <br /> Ground Surlace <br /> SPOILS <br /> grout <br /> Storage Method <br /> Contamination Noted - yes / <br /> Storage ,Location 6✓/ 59 _ tt <br /> SPECIAL PERMIT INFO . _. c <br /> o <br /> slotted = $ <br /> Distance to sewer line section <br /> Domestic well on site - yes / o '— gravel pack <br /> If yes , location distance - <br /> Ye�fte e• <br /> ft <br /> GROUTING <br /> MATERIALS USED : <br /> Depth to water Casing type <br /> Mix Ratios Blank ft . Screen /�o ft . <br /> Installation Method Slot size ry Z <br /> Quantity Installed Bags cement <br /> A / Buckets bentonite <br /> Bags sand / gravel <br /> Filter Pack type / size <br /> Total Billed Time Per Site <br /> Date Permit finalized <br />