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PAGB­Z�_OF / <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: y S - Z U ! ' V CONSTRUCTION <br /> Premise Address: zr-100�'Ifi! Well No. 4, 77- <br /> Inspector: Total Depth s <br /> ;r/x Screen Length !� <br /> Filter Pack <br /> U—S C70 Bentonite P is '5�+ <br /> Permit No. - Grout <br /> Consultant �✓ ` Completion-Stove p' xistie box <br /> GeologJ tL-J ,M <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING -- -- <br /> Holding Temp rature stkk-up <br /> Method T <br /> Screening Meth d T <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet y/n) COMPLETION <br /> COMPLETION <br /> SPOILS --Gmurd S + <br /> proof <br /> Storage Meth04 �—n <br /> Contaminationation oted - yea/no n <br /> Storage Locatiork - n <br /> a <br /> SPECIAL PERMIT INFO. <br /> Distance to sewer lime slonedsection .E <br /> Domestic well on site - yes/no = gm,*Daok <br /> If yes, location & distance - - <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type <br /> Mix Ratios Blank ft. Screen ft. <br /> Installation Method Slot size <br /> Quantity Installed 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 />