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.. ,(GE / OF v <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: 7Z,_ !U CONSTRUCTION <br /> Premise Add sp-tt,6 43 < < C. Cct Well No. <br /> Inspector: Total Depth OF, <br /> Screen Length Zo <br /> Filter Pack`�L:MsC <br /> 1 J� Bentonite Pellets WEl <br /> Permit No. L "�L' 2 Grout �-� ✓ C� <br /> Consultant t1 Completion-Stove pipe/ahristie box--, <br /> Geologist _ <br /> Auger 0.D. <br /> Auger I.D. - � <br /> SAMPLING -- - - <br /> Holding Temperature stick-up <br /> Method 6,w <br /> ri :T <br /> 71 VjScreening Method,(_,_A, <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n)Lt,,,� CONVLETION COMPLETION <br /> Ground Surface <br /> SPOILS <br /> ZZ, grout <br /> Storage Method <br /> Contamination Noted -Cyeii_tno �ft. <br /> Storage Location n, - y 5,V <br /> = a <br /> SPECIAL PERMIT INFO. _ <br /> o <br /> slotted _ c <br /> Distance to sewer line section <br /> Domestic well on site - yes r; <br /> gravel pack <br /> If yes, location & distance <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water S Casing type ➢�'�' <br /> Mix Ratios Blank ft. Screen ZL> ft. <br /> Installation Method Slot sizey-Z 0 <br /> Quantity Installed 13/q/,147 Bags cement fl-F <br /> Buckets bentonite <br /> Bags sand/grave 11i<n.c k;" <br /> Filter Pack type/size �'3 <br /> Total Billed Time Per Site <br /> Date Permit Finalized e/�, - <br /> / <br /> —r--r <br />