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i <br /> .MONITORING WELL INSTALLATION REPORT <br /> i <br /> Date: t �c.� I U CONSTRUCTION <br /> Premise Addr ss: Well. No. <br /> Inspector:^ Total Depth, 3� f <br /> Screen Length <br /> Filter Pack <br /> Bentonite Pellets _3 _ <br /> Permit No. 1� �� Grout 5� y <br /> Consultant Completion-Stove,. pipe christie box <br /> Geologist <br /> Auger 0.D. <br /> Auger I.D. <br /> rfo �a <br /> SAMPLING _ <br /> �a stick-up <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> ABOVE-GROUND CHRISTY-BOX f <br /> Tracking Sheet (y/n) COMPLETION COMPLETION <br /> Ground Surface - + <br /> SPOILS grout <br /> Storage Method <br /> Contamination Noted-- yes/(169 ft. <br /> Storage Location- <br /> a <br /> SPECIAL PERMIT INFO. — c <br /> slatted .- � <br /> Distance to sewer line section '- <br /> Domestic well on site - yes/ pack <br /> If yes, location & distance <br /> =n. = 3B n. <br /> GROUTING 1 I I�`1 Rio <br /> MATERIALS USED: <br /> L1it U � <br /> Depth to water -7" Casing type <br /> Mix Ratios 3-�u aS�Q,I Blank ft-. Screen ft. <br /> Installation Method Slot size ,.OZ <br /> Quantity Installed 2 Bags cement or: <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br /> R <br />