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'AGE Z od <br /> MONITORING WELL INSTALLATION REPORT <br /> • �Z / CONSTRUCTION <br /> Date: <br /> LcJ. /�7MV r Well No. , <br /> Premise Addre s• Total Depth , <br /> inspector; .� <br /> Screen Length ' <br /> Filter Pack _ <br /> Bentonite Pellets <br /> Permit No., l' Z Grout O'�t <br /> Consultant Completion-Stove pipe chXistie bo <br /> Geologist <br /> Auger 0.D. 10 <br /> Auger I.D. - <br /> SAMPLING <br /> !�a stkk•up <br /> Holding Temperat re `f' <br /> Methodl� CAeJ� <br /> Screening Method W T <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet bin)n) COMPLETION COMPLETION <br /> Ground Surtacf <br /> SPOILS <br /> grout <br /> Storage Method Z-3 <br /> Contamination Noted - yes no ft' <br /> Storage Location^ <br /> o <br /> SPECIAL PERMIT INFO. <br /> 0 <br /> slotted <br /> Distance to sewer line U wcdon <br /> Domestic well on site - ye /n <br /> pack <br /> If yes, location & distance- <br /> GROUTING <br /> MATERIALS USED:: ,, <br /> r <br /> Depth to water�l ` V <br /> C " r Z' Casing type-/ <br /> Mix Ratios Blank & ft. Screenft. <br /> Installation Method A41AZ Slot size _C>6?— <br /> Quantity Installed r Bags cement G( <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size43 <br /> Total Billed 'Time Per Site <br /> Date Permit Finalized <br />