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pAGE___LOF t <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> CONSTRUCTION <br /> Premise Address: ww b l�� Well No. tri W Y� <br /> Inspector• Total Depth 7T7/_ <br /> Screen Length a-f� <br /> Filter Pack a-b <br /> Bentonite Pellets <br /> Permit No. � Grout er Ll <br /> Consultant Completion-Stove= pipe rist-ke-tsa3i'- <br /> Geologist <br /> ll <br /> Auger O.D. (� <br /> Auger I.D.�o/2- " <br /> n� <br /> SAMPLING(S <br /> Holdi ---- — -- -- <br /> 1 " �ng aturstick-up <br /> Tempere <br /> Method <br /> Screening Method T <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) COMPLETION COMPLETION <br /> Ground Surface —+ <br /> SPOILS <br /> grout <br /> Storage Method 1 Cyn. <br /> Contamination Noted - ye <br /> Storage Location Win. <br /> a <br /> SPECIAL PERMIT INFO. o <br /> slotted = c <br /> Distance to sewer line section _ <br /> Domestic well on site - yes/' o _ y�rgpagt <br /> If yes, location & distance <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing ty e <br /> Mix Ratios ' ^ E a sQ Blank ft. Screen _ft. <br /> Installation Method Slot size <br /> Quantity Installed Bags cement o- q4 Mr <br /> Buckets bentonite 1 <br /> Bags sand/gravel <br /> Filter Pack type/size3 <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />