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WAGE (0 OF !� <br /> MONITORING WELL INSTALLATION REPORT <br /> K�,�ne�/den k-5/ rh%'1A"7 <br /> le <br /> Date: /�U - d// '�/ �o CONSTRUCTION <br /> Premise Address: Z"",/1 v/ fL Well No. <br /> Inspector: Total Depth <br /> 177' Screen Length /� �^ <br /> Filter <br /> Bentonite Pellets OS <br /> Permit No. Grout <br /> Consultant L .�a ii C�+gnf C Completion-Stove pipe/christie box <br /> Geologist v �/ ® /o✓n�l/3 _ <br /> Auger O.D,/ V r- /�- <br /> Auger,Z�'D. <br /> SAMPLING _.. <br /> Holding Temperature •dck'up <br /> Method <br /> Screening Method <br /> ABOVEGROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) COMPLETION COMPLETION <br /> SPOILS Ground S �— <br /> proof <br /> Storage Method //JC 4M ,]/- <br /> Contamination Noted - ye /no �n• <br /> Storage Location o� 51 Z n• <br /> n. <br /> e <br /> SPECIAL PERMIT INFO. <br /> o <br /> Distance to sewer line saktian = $ <br /> Domestic well on site - yes/no _ �� <br /> If yes, location & distance - <br /> pack <br /> CJS <br /> GROUTING <br /> MATERIALS USED: LLQQ'' <br /> Depth to water / Casing type �T�� ` - +wdcns� scre-e/ <br /> Mix Ratios Blank ft. Screen Zo ft. <br /> Installation Method Slot size <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized /� (' <br />