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ME OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Well No. <br /> Ins_oector: Total Depth <br /> Screen Length <br /> Filter Pack <br /> Bentonite Pellets <br /> Permit No. Grout <br /> Consultant Completion-stove pipe/christie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING <br /> Folding Temperature �stickup <br /> Method r Fr 77 v <br /> _�j%� T <br /> Screening Method ,_ <br /> AE&E-GRCUND CMRISTY-BOX <br /> Tracking Sheet (y/n) CCWL,ION CCMPL-'TION <br /> Ground Surface <br /> SPOILS <br /> grout <br /> Storage Methodpo -- ft <br /> Contamination Noted - yes/no <br /> Storage Location <br /> 0 <br /> m <br /> SPECIAL PERMIT_ INFO. <br /> o <br /> ¢lotted = � <br /> Distance to sewer line sec^:on <br /> Domestic well on site - yes/no 1. <br /> 72yw Pack <br /> If ves, location & distance - <br /> i <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type <br /> Mix Ratios Blank ft. Screen ft. <br /> Installation Method Slot size <br /> Quantity installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> .filter Pack tvpe/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />