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ues i <br /> .jb./p?a0 , A OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date• ` Z CONSTRUCTIfO�N cy <br /> Premise Add ess: �0 A), � - Well No. <br /> Inspector• l� Total Depth � .. <br /> Screen Length��/� <br /> Filter Pack <br /> Bentonite Pel ets ! S� <br /> Permit No. Grout <br /> Consultant Completion-Stove pipe/christie box <br /> Geologist <br /> Auger O.D. Z- <br /> Auger I.D. " �� <br /> SAMPLING g �-(,cv-z'{ <br /> stick-up u <br /> Holding Temperaturelff�l <br /> Method / T <br /> T <br /> Screening Method 9 IN <br /> ABOVEGROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) 00wPLETION COMPLETION <br /> Ground Surf acs f qI� <br /> SPOILS Groin <br /> Storage Method <br /> Contamination Noted - yes/no <br /> Storage Location n, _ <br /> m <br /> Y <br /> SPECIAL PERMIT INFO. c <br /> slotted = 8 <br /> Distance to sewer line section —' <br /> Domestic well on site - yes/no = pravelpudc <br /> If yes, location & distance - <br /> GROUTING <br /> j� MATERIALS USED: <br /> Depth to water v L Casing type <br /> Mix Ratios Blank 3() _ ft. Screen j: ft. <br /> Installation Method Slot size 4)U <br /> Quantity Installed Bags cement�4J <br /> Buckets bentonite I <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />