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AGE OF <br /> �v MONITORING WELL INSTALLATION REPORT <br /> Date: / CONSTRUCTION <br /> Premise Addr ss: :�/7s- ev• r Well No. <br /> Inspector: V Total Depth L <br /> Screen Length <br /> Filter Pack <br /> Benton to Pellets <br /> Permit No. v W Grout HAMLk <br /> Consultant�9456 Completion-Stove pipe/christie box <br /> Geologist Gem SNI) <br /> Auger O.D. �Z` <br /> Auger I.D. <br /> SAMPLING — -- — <br /> Holding T mperature stick-up <br /> Method "e-ey _ <br /> Method. <br /> Screening Method <br /> /�190VE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) COMPLETION COMPLETION <br /> Ground Surface <br /> SPOILS y <br /> grout <br /> Storage Method <br /> Contamination Noted - yes/no <br /> Storage Location <br /> ' 71� <br /> P <br /> SPECIAL PERMIT INFO. c Zf <br /> s�Ottad = C <br /> Distance to sewer line socdon _ <br /> Domestic well on site - yes/no = � P <br /> If yes, location & distance - <br /> tt. <br /> GROUTING <br /> MATERIALS USED: <br /> I t 'l <br /> Depth to water �_ ! Casing type qv /u C <br /> Mix Ratios Blank__p ft. Screen ft. <br /> Installation Method Slot size .D <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel 1W <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br /> 51 Xrrq,[ / l <br /> . f te <br />