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Y.. <br /> - MONITORING WELL INSTALLATION REQ ' <br /> LL: ae: , 0/ CONSTRZ I <br /> Premise Address: <br /> .T ,f Well No. <br /> Inspector: Total Dept <br /> SOS Length - <br /> Filter Pack <br /> Bentonite Pellets S i <br /> Pers%it No. Grout 1/3' <br /> Consultant Completion-Stove.pipe Christie box <br /> Geol t x, <br /> eo,50n Auger O.D. <br /> Auger I.D. <br /> _ 1 <br /> --mading 'Temperature `t' c �ls� ted) &**-UP <br /> a - <br /> Scre `? �r! <br /> ABOVE-GROUND CFPASTY•BOX <br /> Tracking Sheet (y/n} COMPLETION CO1tON <br /> Ground&go= •+•^� <br /> grout <br /> Storage ,.11hod <br /> Contamite~tion Noted - yes ' <br /> Storage L®r� tion ' <br /> sr ...n. _ <br /> SPECIAL PERMIT INFO. " 'jK_ <br /> r <br /> � tbtpd <br /> Distance to sewer Sin /DD :, x <br /> r 'Daeestic'well on site - yes no <br /> padt <br /> If yes, location & distance r t <br /> lip <br /> (;ROUTING <br /> MATERIALS USED: <br /> Depth to water Z Casing type <br /> Mix Ratios Blank_%,f ft. Screen ft. W.. <br /> Installation Method +yp - Slot size 0 Z40 <br /> Quantity Installed ' Bags cement ` <br /> Buckets bentonite <br /> Bags" sand/gravel <br /> Filter Pack type/s— ze <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br /> { <br />