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AGE__� OF_/—_ <br /> MONITORING WELL INSTALLATION REPORT <br /> Date:"�(W6 CONSTRUCTION <br /> Premise Addres ' ��-� - -C�4R- t" Well No':.'� � <br /> Inspector: Total Depth <br /> Screen Length ;-70 <br /> Filter Pack 11__t, <br /> / Bentonite Pellets E� <br /> Permit No. �� If Grout .- <br /> Consultant <br /> rout Consultant Completion-Stove pipe chrlstie. ox <br /> Geologist aA­4Z- <br /> Auger 0.D. UU <br /> Auger I.D.R' <br /> SAMPLING -- -- - <br /> Holding Temperature abch-up <br /> Method <br /> Screening Method ' <br /> AgoVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) /.v-- = COWPLETION COMPLETION <br /> Ground Surface <br /> SPOILS <br /> proof <br /> Storage Method ��{�'� ro C <br /> Contamination Noted es/no <br /> Storage Locatios7a .lea _ <br /> = a <br /> SPECIAL PERMIT INFO. = c <br /> SSC>' slonod <br /> Distance to sewer line,� section —_ <br /> Domestic well on site - yesfnc,' _ g-vW pack <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water �5' / Casing type 4'/ 1>0(l _ <br /> Mix Ratios !�^� '� " ' Blank ft. Screeneft. <br /> Installation Method /l ez • z Slot size D [i <br /> Quantity Installed ;-t Bags cement L t <br /> Buckets Benton to J >- <br /> Bags sand/gravel / <br /> Filter Pack type/size S/t f <br /> Total Billed Time Per Site <br /> Date Permit Finalized 7L(� <br />