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• PAC4k _OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Well No. <br /> Ins_oector: Total Deoth <br /> Screen Length '- <br /> Filter Pack <br /> Bentonite Pellets' <br /> Permit No. Grout <br /> Consultant Completion-stove pipe/christie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING <br /> Holding Temperature <br /> . _ �sOck-up <br /> Method <br /> Screening Method <br /> ABOVE GROUND CNRISTY-BOX <br /> Tracking Sheet (y/n) cCWi-F'CN CCMPL'TION <br /> C-rwrd Surface T. <br /> SPOILS <br /> grout <br /> Storage Method ro n <br /> Contamination Noted - yes/no �'— <br /> Storace Location ft ft. <br /> _ m <br /> d <br /> SPECIAL PERMIT INFO. <br /> slotted ZZ, = c <br /> Distance to sewer line saclon <br /> Domestic well on site - yes/no <br /> IP ves, location & distance - ;< <br /> 7av'Eq PackI <br /> GROUTING - <br /> MATERIALS USED: <br /> Depth to water Casing type <br /> Mi:c Ratios Blank ft. Screen ft. <br /> Installation Method Slot size <br /> Quantity _installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Dtal Billed Time Per Site <br /> ate Permit Finalized <br />