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MONITORING WELL INSTALLATION REPORT <br /> Date: w / CONSTRUCTION <br /> Premise Address: 3���yr�., r.',� Well No. Tl <br /> Inspector• Total Depth .c7 <br /> Screen Length <br /> Filter Pack <br /> r <br /> qu Bentonite 11-_ �s <br /> Permit No. ` Grout 6 'Z <br /> Consultant Completion-Stove pipe/christie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING <br /> so&-up <br /> Holding Tern erat re <br /> Method <br /> Screening Method � <br /> ABOVE-GROUND CHRISTY-BOX <br /> QWT <br /> Tracking Sheet (y/n) COMPLETION COMPLETION <br /> Ground Surface <br /> SPOILS <br /> gfOLJt <br /> Storage Method ft. <br /> Contamination Noted - yes/no <br /> Storage Location ( _ , <br /> a <br /> SPECIAL PERMIT INFO. o <br /> slotted <br /> Distance to sewer line 7 vection <br /> ir <br /> Domestic well on site - yes/,EOgrayefpadc <br /> I£ yes, location & distance - <br /> GROUTING r � <br /> MATERIALS USED: <br /> Depth to water Casing type v `� <br /> Mix Ratios Blank •02- ft. Screen - --ft. <br /> Installation Method Slot size. <br /> Quantity Installed &4-Buckets <br /> Bags cement <br /> bentonite <br /> Bags sand/gravel 3 <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />