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"AGE OF <br /> MONITORING WELL INSTALLATION RWOjt1 <br /> 7'�77 a <br /> Date.• _ i CONSTRUCTIO <br /> Premise Address: N+ <br /> inspector: Total Depth <br /> Screen Length <br /> Filter 'Pack <br /> Bentonite Pellets <br /> Permit: No.., Grout <br /> Consultant <br /> }� :. � Completion-Stove.pipe/chriatis box <br /> Geololiat, <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING _•._._ <br /> Holding Temperature s t-up <br /> Method X, <br /> - <br /> aet7 1 <br /> Screening Method ......... <br /> ..... ABOVE4RWND CHRi5 -BOX <br /> Tracking Sheet (y-/h) COMPLETION Gt MPLETiON <br /> SPdILS Gmun d Surtax ••�••� <br /> W&A <br /> Storage Method SIB. <br /> Contamination Noted - (as) <br /> es no <br /> Storage Location , <br /> ft. <br /> a <br /> SPECIAL PERMIT INFf} <br /> Distance to sewer line arti �• $ <br /> Domestic well on site - yes/ncs <br /> If yes, location & distance Pack. <br /> 'fit«.. <br /> GROUTZNa <br /> MATERIALS USED: <br /> Depth to dater: Casing type <br /> Mix Ratios ...... Blank_. :ft:. Screen ft.. <br /> Installation Method Slot size <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags saind f grayel. <br /> Filter Pack typp/gize <br /> 'dotal. Billed Time. Per. Site <br /> • <br /> Date Permit Finalized <br />