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. ( E OF <br /> { �d <br /> MONITORING WELL INSTALLATION REPORT <br /> r <br /> 4- <br /> Date: CONSTRUCTION <br /> Premise Addres: Well No. W <br /> ��o� �. fid,.: <br /> Inspector: Total Depth 2Z- <br /> Screen Length 2 <br /> Filter Pac�k{',�,Z. <br /> Bentonite (.4 <br /> Permit No. Grout i <br /> Consultant r Completion-Stovepipe/christie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. 17 - <br /> SAMPLING ---_-- -- - <br /> sUck-up <br /> Holding Temperature <br /> Method <br /> Screening Method ,. <br /> ABOVE-GROUND <br /> Tracking Sheet (y/n) COMPLETION COMPLET ON ' <br /> Ground Surface <br /> SPOILS <br /> grout <br /> Storage Method LUU1 <br /> Contamination Noted - es� <br /> i <br /> Stora a Location — <br /> 0 <br /> — a <br /> SPECIAL PERMIT INFO. _ o <br /> slotted = C <br /> Distance to sewer line �� section = <br /> Domestic well on site - yes grsvelpack <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> 1! �M <br /> Depth to water Casing type (11Z <br /> Mix Ratios Blank ft. Screen 17 ft. <br /> Installation Method Slot size <br /> Quantity Installed Bags cement <br /> Buckets bentonite r ( , <br /> Bags sand/gravel <br /> Filter Pack type/siz 3 <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />