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y <br /> �' . • %W1GB OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: I ( �I S_ D „• ._ CONSTRUCTION <br /> Premise Address: bfxb Well No. 100 ' �J <br /> Inspector: Total Depth "SO` <br /> 5• ��l�f.�t31�� 1 Screen Length -491 <br /> Filter Pack '-'SO' <br /> Bentonite Pellets -4UI -3S/ <br /> Permit No. r'tC7 - ZZ Grout -8- <br /> Consultant_ [:2f-1 - WLSi' Completion tove pipe christie box <br /> Geologist Sl;h kR3-K( sp'j�j I t2(1 <br /> Auger O.D. <br /> Auger I.D. �.2t <br /> SAMPLING - - - — <br /> Holding re4z <br /> stick-up <br /> Method T7 <br /> P, <br /> Screening filet d <br /> C' ABOVE-GROUND CHRISTY-BOX <br /> Trackin heet (y/n) COMPLETION COMPLETION <br /> Ground Surface ��•� <br /> SPOILS <br /> grout <br /> Storage Method <br /> Contamination Noted -- (ve-sj>no ' <br /> Storage Location ft' <br /> 6xi <br /> 0 <br /> SPECIAL PERMIT INFO. _ <br /> _ n <br /> Distance to sewer line �iSb "don � <br /> Domestic well on site - yes/no grayWP <br /> ack <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: / <br /> Depth to water I Casing type 1A-- 4-0 IN(- <br /> Mix Ratios Blank _!1L __ _- ft. Screen ft. <br /> Installation Method F AL4'— Slot size _ [� . Ol0_- <br /> Quantity Installed Bags cement <br /> Buckets bentonite 2. 011,rli � <br /> Bags sand/gravel <br /> Filter Pack type/size I <br /> Total Billed 'Time Per Site <br /> Date Permit Finalized CONFIDENTIA1 <br />