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NONITORING WELL INSTAWLTION REPQRT <br /> Hate= J 9d <br /> Premise Addr as Well No. �S <br /> Inspector Total Total Depth <br /> Screen Length <br /> Filter Parc <br /> Permit No. <br /> O! �,�� Bentonite Pellets tlt�Consult Grout - S <br /> Geologist gyCompletion-Stove piaChrfstie bo <br /> I_ <br /> Auger 0.D. <br /> Auger 1.D. <br /> Holding T atureAL_ <br /> Method <br /> Screening Method <br /> ABOVE-GROUND CHFItSN-BOX <br /> Tracking Sheet (y/n) COWLEnON <br /> C0NAPI.ETIQt4 <br /> AMLS ow d Surfas 11 <br /> Storage Method <br /> aOL4 <br /> Contamination Not - vem. <br /> C rage hoc tion o CS — }i <br /> �A. <br /> ON <br /> r!PxCUQ POWIT IHM <br /> Distance to sewer line m1o�Md <br /> Domestic well on site - yea/no <br /> If yes, location i distance - '; PW* <br /> fill• <br /> >. fL <br /> gxo�rrn�a <br /> qZDJ <br /> Depth to water �� � Casing type. <br /> Hix Ration Blan - ft. Screen ft. <br /> Installation Method Slot size_ /yy' p <br /> Quantity Installed S -- ��Z�'-'—�"-'� <br /> Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> C(OPY <br />