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iGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date : ( ( CONSTRUCTION <br /> Premise Add re s : 53 0 Vi �i .. Well No . : {L( <br /> _ <br /> Inspector : Total Depth IL <br /> Screen Length <br /> Filter Pack /-� <br /> Bentonite Pellets _y -+ • � f• <br /> Permit No . ! �O`�' Grout 0 � • .o <br /> Consultant V Completion- Stove pipe / christie box <br /> Geologist <br /> Auger O . D . S3I4• <br /> j Auger I . D . <br /> SAMPLING - -- <br />� - - <br /> Holding Temperature sdck-up <br /> M thodC -PSC-� � L <br /> nroup <br /> d� .11- <br /> Screening Method NO sA o+�yw <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet y/ ) COMPLETION COMPLETION <br /> �.� Ground Surlaca <br /> SPOILS <br /> -- proof <br /> Storage Metho 0•n 0.54 1 Z - <br /> Contamination Note - WV ? <br /> Storage Location —n 8 n. <br /> SPECIAL PERMIT INFO . <br /> 0 <br /> 2 $ � slotted <br /> Distance to sewer line action <br /> Domestic well on site - yes / no = <br /> gr&vW pack <br /> If yes , location & distance - <br /> Ap _a. - n. <br /> GROUTING <br /> MATERIALS USED : <br /> Depth to water " 2• ) Casing ty a Z ,I 1`" V ` � �� <br /> Mix Ratios Blank 1 ft . Screen 15 ft . <br /> Installation Method Slot size . 0111. <br /> Quantity Installed Bags cement <br /> Buckets bentonite • 33 <br /> Bags sand / gravel <br /> Filter Pack type / size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br /> a 2 - i / W <br />