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AGE OF4- <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: 2 7 CONSTRUCTION <br /> Premise Address: ` D� W Well No. M UIV�i <br /> Inspector: 1-"A-Cgn_ Total Depth_ <br /> Screen <br /> -53 Filter Pack q <br /> t3 ' : ,Q Bentonite Pe 3.7 <br /> Permit o. Grout <br /> Consultant Completion-Stove.. pipe/Christie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING <br /> Holding Temperature <br /> stick-up <br /> Method CJLI,t4 6 A <br /> Screening Method <br /> AE&E-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n� COMPLETION COMPLETION <br /> Ground Surface <br /> SPOILS <br /> grout <br /> Storage Method <br /> Contamination Noted - yes no) ft' <br /> Storage Location <br /> M <br /> a <br /> CD <br /> SPECIAL PERMIT INFO. <br /> 0 <br /> slotted = <br /> Distance to sewer line > >" section "- <br /> Domestic well on site - yes = qn;WPack <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type Pyr.,- Zii <br /> Mix Ratios Blank_ ft. Screen / 5 ft. <br /> Installation Method Slot size •�"L <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags and/ ravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />