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.GE__LOF__I_ <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: ` CONSTRUCTION <br /> Premise Address: I m u'y tC_ 0�0- o Well No. M Lj I <br /> Inspector: Total Depth <br /> • o. ; Screen Length :3 2. - 7•S <br /> Filter Pack 32- .;-- 0 <br /> Bentonite Pellets <br /> Permit No. ( 2- -` Grout - / <br /> Consultant r Completion-Stove• pip(;-Ichristie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING - - — -— <br /> 1 stick-up <br /> Holding Temperature ) C-e <br /> Method <br /> S On <br /> Screening Method p/m ._ <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y ) COMPLETION COMPLETION <br /> Ground Surface <br /> SPOILS <br /> grout <br /> Storage Method V-ln3 <br /> Contamination Noted - yes o ��i+r 0 <br /> Storage Locati n <br /> (11 � Si <br /> — a <br /> SPECIAL PERMIT INFO. `� /��S• = c <br /> 0 <br /> slottod — c <br /> Distance to sewer line-"- socton <br /> Domestic well on site - yes/� _ graveI pack <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> D <br /> Depth to water 2 Z ' Casing type r � <br /> Mix Ratios Blank 7 ft. screen. ft. <br /> Installation Method Slot size 0 Z <br /> Quantity Installed Bags cement <br /> Buckets bentonite / <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site ?j� OC,/ <br /> Date Permit Finalized Z o <br />