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r <br /> �E__LOF , <br /> MONITORING WELL INSTALLATION REPORT <br /> Date:_ � G _ CONSTRUCTION <br /> Premise Address: Well No. <br /> Inspecto aC/7 l ' Total Depth Z� <br /> f Screen Length_/g- <br /> Filter Pack <br /> Bentonite PesS)vrru 3 <br /> Permit No. d" <br /> 3 S 3316 ' Grout d'ncrc 3 <br /> Consultant 4 Completion-Stove pip ch <br /> GeologiSt <br /> Auger O.D. <br /> Auger T.D. <br /> SAMPLING <br /> adds-up <br /> Holding Temperature <br /> Method <br /> r ¢ � <br /> Screenin <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y COMPLETION COMPLETION <br /> Cirnund Suaiace <br /> SPOILS /,��y.e'/ / grout <br /> Storage Method J kn? q� /! �.ft. <br /> Contamination No ed - yes/�r�� ft, <br /> Storage Location .r..ft. <br /> m <br /> a <br /> _ m <br /> SPECIAL PERMIT INFO. _ <br /> 0 <br /> Batted � <br /> Distance to sewer line taction <br /> Domestic well on site - yes/no _ gravel pads <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> e <br /> Depth to water�T�� _ Casing type <br /> Mix Ratios .s Prt� ' � � Blank ft. Screen ft. <br /> Installation Method 3�' e9 Slot size r� <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site )/y�Li "3 '141 <br /> Date Permit Finalized <br />