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*GEdLOF_� <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: �� y0 CONSTRUCTION nA <br /> Premise Address: .-Nld✓/ [�'/ �f c- Well No. /�� �✓ <br /> Inspector• Total Depth <br /> Screen Length <br /> Filter Pack <br /> Bentonite Pellets <br /> Permit No. ( 'ZUa Grout <br /> Consultant Completion-Stove, pi /christie box <br /> Geologist � Auge <br /> �f l�s4 ec D rI� J6.a r O.D. ✓ d /c.� <br /> / Auger I.D. <br /> SAMPLING <br /> stick-up <br /> Holding Temperature <br /> Method <br /> Screening Method ... <br /> ABOVEGROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) COMPLETION COMPLETION <br /> Ground Surlacs <br /> SPOILS grout <br /> Storage Method/✓�3 .R. ' <br /> Contamination Noted - yes no }(, <br /> Storage Location mn S. }(, <br /> "- Td <br /> _ o <br /> r <br /> SPECIAL PERMIT INFO. - o <br /> 1' s slotted <br /> )p Distance to sewer line sic^ <br /> �tl Domestic well on site - yes/no — pnwlpack <br /> If yes, location & distance <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type <br /> Mix Ratios Blank Z-(0 ft. screenYO ft. <br /> Installation Method Slot size C ,25 <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 />