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c <br /> JAL <br /> • *E�OF�_ <br /> �I�5 MONITORING WELL INSTALLATION REPORT <br /> Date:- � - "o CONSTRUCTION <br /> Premise Address: Z'('?C014 j/C1('t. Well No. � W O <br /> Inspector: / Total Depth <br /> Screen Length <br /> Filter Pack & J`- `� 7• 2 <br /> Bentonite Pellets <br /> Permit No. Zd2..- YS . 3 - / <br /> /'� Grout <br /> Consultant LeecPs h; ✓Gch�o'4- Completion-Stove, pipgTchristie box-� <br /> Geologist M, Ce E-12 <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING - -- <br /> Holding Temperature dkk'up <br /> Method Iffl <br /> 7M IV <br /> _IEWT <br /> Screening Method <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y COMPLETION COMPLETION <br /> SPOILS Ground Surface <br /> PERproal <br /> Storage Method <br /> Contamination Noted - ye �tt• <br /> Storage Location n• <br /> ®/( <br /> SPECIAL PERMIT INFO. <br /> / - o <br /> dotted <br /> S $ <br /> Distance to sewer line vection <br /> r6� <br /> Domestic well on site - yes/ _ (ia�slpack <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> j <br /> Depth to water_ � ,Se /Casing type V C <br /> [- <br /> Mix Ratios Blank ft. Screen ft. <br /> Installation Method Slot size O Z. <br /> Quantity Installed Bags cement <br /> Buckets bentonite I <br /> Bags sand/gravel S <br /> Filter Pack type/size 7 <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />