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• r r � 1 <br /> AGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: 11 CONSTRUCTION <br /> Premise Address: -S C4-ZC4j Well No. A-j Z <br /> Inspector: Total� Depth <br /> �Gc,� Screen 'Length <br /> Filter Pack <br /> Bentonite Pellets, -40•5' ' �3 ` <br /> Permit No. qD 'So ZZ Grout - 3 S <br /> Consultant s c Completion-Stove pipe c rest a ox <br /> Geologist S0n9o24J0b1 53k= LEL <br /> - Auger O.D. b..L . <br /> Auger I.D. <br /> SAMPLING — — <br /> stick-up <br /> Holding Temperature <br /> Method <br /> 1-4 <br /> 7 <br /> Screening Mot od <br /> ABOVE-GROUND CHRISTY•Box <br /> Tracking heet (y/nl.) - COMPLETION COMPLETION <br /> Ground Surface <br /> SPOILS <br /> grout <br /> Storage Method <br /> Contamination Noted - d9�rjno <br /> tt. <br /> Storage Location .., _rt• <br /> p <br /> SPECIAL PERMIT INFO. o <br /> slotted <br /> Distance to sewer line ` &action <br /> Domestic well on site - yes/no �yqpack <br /> If yes, location & distance - <br /> F <br /> i GROUTING <br /> MATERIALS USED: <br /> t <br /> It <br /> Depth to water Casing type SCl4 4i3 .PJ C- <br /> 4�' <br /> Mix Ratios Blank _A- ft.` Screen <br /> _,_, _ft. <br /> h Installation Method 11�72�►j-�Nj[(.r- Slot size O. <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size t 26 <br /> f Total Billed Time, Per Site <br /> Date Permit Finalized CONFIDENTiAL <br />