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savoiPAGB OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: 7s / / CONSTRUCTION <br /> Premise Address: 3� '~ or. � Well No. <br /> Inspector: Total Depth <br /> Screen Length �� Yx 1�5 �. <br /> Filter Pack <br /> Bentonite Pellets <br /> Permit No. a -iy�3 _ Grout' 29' 7 f- 3? 'e .Scat <br /> Consultant Completion-Stove pipe/ hrj. tie ox <br /> Geologist :P�! �rf <br /> Auger O.D. O <br /> Auger I.D. <br /> SAMPLING - _ �- <br /> Holding Temperature �/ - stick-up <br /> Method <br /> Screening Method co U.-f T <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) oowPLETION COMPLETION <br /> Ground Surtaos + ^..�� <br /> SPOILS <br /> grout <br /> Storage MethodG <br /> Contamination Noted - yes/ <br /> Storage Location <br /> a <br /> m <br /> SPECIAL PERMIT INFO. _ o <br /> slottod c <br /> Distance to sewer line .�� sac>ron <br /> Domestic well on site - yes tmvelpack <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type 4�10 /'Vc <br /> Mix Ratios '2 �lc� _ BlankL__j�� ft. Screen Z ft. <br /> Installation Method Slot size O' ", <br /> Quantity Installed Bags cement <br /> Buckets -bentonite <br /> Bagssand gravel <br /> Filter ack type/size t -„ � <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />