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3E OF <br /> N <br /> MONITORING WELL INSTALLATION REPORT <br /> CONSTRUCTION <br /> Date : `` II '' II �I,� � � / <br /> Premise Address : 11✓,30 W � OCL Well No . 1441 <br /> Inspector • Total Depth <br /> Screen Length /� -•�• /(v <br /> ' Filter Pack /e <br /> Bentonite Pellets <br /> Permit No . 9l- O &o Grout 0 <br /> Consultant Completion-Stove pipe / christi ox <br /> Geologist b14ic.+ <br /> Auger O . D . <br /> Auger I . D . <br /> SAMPLING <br /> stick-up <br /> Holding Temperature <br /> Method C)3"l. �/L�•R-R <br /> Screening Method <br /> ABOVEGROUND CHFiISTYWX <br /> Tracking Sheet � n ) COMPLETION COMPLETION <br /> - Orourd Swtace <br /> SPOILS <br /> grout j <br /> Storage Method &L ►/ SQ , 3 tt• <br /> Contamination Noted - es no g fl <br /> Storage Lpcation / n _ <br /> SPECIAL PERMIT INFO . = o <br /> 5 ( / / dotted _ 8 <br /> Distance to sewer line k4Adj4:* •� section <br /> Domestic well on site - / no = gmW pack <br /> If yes , location & distance - -_ <br /> GROUTING <br /> MATERIALS USED : <br /> Depth to water��� Casing type <br /> 0;1 PVC <br /> Mix Ratios Blank / ft . Screen / ft . <br /> Installation Method Slot size • (�D <br /> Quantity Installed Bags cement <br /> Buckets bentonite . 3 3 <br /> Bags sand / gravel y 2 <br />! Filter Pack type / size— __ — <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />