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(AGE�OF <br /> `ter •>� <br /> a - - <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: U 15 CONSTRUCTION <br /> Premise Addr &Of S (�t� Well No. <br /> Inspector: �QbC/+� Total Depth <br /> Screen Length <br /> ir <br /> Filter Pack 36"- /Z <br /> Bentonite Pellets .Z-- O ! �� <br /> Permit No. Grout d-- 5 <br /> Consultant I Completion-Stove pipe/ ie ox <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING -----._._ — <br /> Holding Tem eraturea­ <br /> VE-GROUND <br /> S*k-up <br /> Method <br /> L <br /> Screening Method asp <br /> CHRIS7Y-BOX <br /> Tracking Sheet (-Y> <br /> y ) COMPLETION <br /> Ground Surface <br /> SPOILS <br /> grout <br /> Storage Method /Q <br /> Contamination Noted - yes/no Z n. <br /> # Storage Location eft. <br /> If, <br /> 1 p <br /> _ m <br /> SPECIAL PERMIT INFO. o <br /> slotted = c <br /> _Distance to sewer line section <br /> Domestic well on site - yes/nogravw <br /> If yes, location & distance - ` <br /> 16::ft. <br /> f GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type_ <br /> Mix Ratios Blank ft. Screen Zd 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 />