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vPAGE OF <br /> NONITORINA WELL INSTALLATION REPORT <br /> Date:SIS D CONSTRUCTION <br /> Premise Addr s OAU Well No. � <br /> Inspector: Total Depth <br /> Screen Length/D <br /> Filter Pack 1 <br /> Bentonite Pellets ' 5 T <br /> Permit No. Grout CQ.(....._-,t _ <br /> Consultant _' Completion-Stove pipe/chxistie box <br /> Geologist <br /> Auger 0.D. 3 <br /> Auger I.D. <br /> SANPLIN(� — <br /> ° stk*-up �/`�____ <br /> Holding Temperature C/ �' <br /> Method /�.l Q T f <br /> Screening Method <br /> ABOV"ROUND CFPLSiY4W <br /> Tracking Sheet (y/n) COMPLETION COAAPt�T10N <br /> Grotxd Surlaas <br /> SPOILS <br /> Storage Method _ . <br /> Contamination Noted - yes no _ <br /> Storage Locat ion,r,,,_ �. <br /> o <br /> M <br /> SPECIAL PERMIT INFO. , <br /> Distance to sewer line « <br /> Domestic well on site - yes/no <br /> If yes, location & distance - <br /> ;r <br /> �, = Z� �. <br /> aROUTINa _ <br /> MATERIALS USED: <br /> Depth to water 2/ Casing type <br /> Mix Ratios Blank_0 ft. Screen b ft. <br /> Installation Method ,D&�% Slot size .6Z— <br /> Quantity <br /> bLQuantity Installed / Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel_( <br /> Filter Pack type/size <br /> Total Billed 'Time Per Site , <br /> Date Permit Finalized <br />