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%...iPAGE__�`OF_�_ <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: o / CONSTRUCTION <br /> Premise Add re s: �Z�b Well No. 5A - _ <br /> Inspector: .� Total Depth <br /> — <br /> Screen Length 13 42 <br /> Filter Pack 63 <n f <br /> Bentonite Pellets 4!p-G -- <br /> Permit No. '--0_ ��3 Grout &_ <br /> Consultant_fA E_QvCompletion-Stove pipe/ r sti box <br /> Geologist . e /+/< _ <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING - - - <br /> Holding Tem erature C_ stkk-uP <br /> Method rw <br /> Screening Method (I ✓^1 <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (9n) OOWPLETION COMPLETION <br /> Ground Surf we <br /> SPOILS <br /> .�,�- grout <br /> Storage Method %� -�-r ft. <br /> contamination Noted - yes/67 ft. <br /> storage Location a*,, & _ft. __P_1 <br /> _ o <br /> m <br /> SPECIAL PERMIT INFO. o <br /> / S104d <br /> Distance to sewer line yS� section <br /> Domestic well on site - yes(/�rro� = graYq pack <br /> If yes, location & distance <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water casing type S'c// Ste' r?dG �i <br /> Mix Ratios 21A 5"k m Blank ft. ScreenLr� ft. <br /> Installation Method slot size ©. <br /> Quantity Installed Bags cement <br /> Buckets bentonite 1 <br /> Bags sin /gravel <br /> Filter Pack type/size Z <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />