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N WAGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: 5� u CONSTRUCTION <br /> Premise Address: Well No. IOw - <br /> Inspector: Total Depth _!:� r <br /> �j �yj�WZ_' Screen Length <br /> Filter Pack - SO' -40 <br /> Bentonite Pellets -I:() - 39/ <br /> Permit No. g0 - 30 2Z Grout --381, - 4�0-- <br /> Consultant I£121l - WAST Completion--Stove pipe christie box <br /> Geologist _'-0*?JPJ0AJ SAzb .- <br /> Auger O.D. Za <br /> Auger I.D. <br /> SAMPLING - --- - -- <br /> Holding Temperature slldc-up <br /> Method <br /> Screening flet _ <br /> D ASOVE4ROUND CHRISTY-BOX <br /> Tracki Sheet (y/n) OOMPLUION COMPLETION <br /> Ground Surlw* <br /> SPOILS <br /> grout <br /> Storage Method_ <br /> Contamination Noted - yee no <br /> Storage Location h' <br /> cp l S of _5 <br /> p <br /> O <br /> SPECIAL PERMIT INFO. <br /> 0 <br /> � slotted = E <br /> Distance to sewer line 7S0 sacdon <br /> Domestic well an site - yes/no <br /> If yes, location & distance - <br /> GROUTING 01 <br /> MATERIALS USED: <br /> Depth to water Casing type_SG 4-0 FVC- (4�•� <br /> Mix Ratios— <br /> �I 5/a � Blank _ Al___ ft. Screen�ft. <br /> Installation Method P t• j&_ Slot size O10 <br /> Quantity Installed Bags cement <br /> Buckets bentonite 2 C is <br /> Bags sand/gravel <br /> Filter Pack type/size ZC� <br /> Total Billed 'Time Per Site <br /> CONFID' <br /> Date Permit Finalized <br />