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V b <br />*GB OIC' <br />MONITORING WELL INSTALLATION REPORT <br />Date: /c' Jq&V <br />Premise Address: P ®F®&( - <br />Inspector: /® e� <br />Permit No. 96a67 -6 - <br />consultant 'L& <br />67,6- <br />consultant'L& A ® I <br />Geologist 's zv'I E4 <br />Holding T'Wnper ure <br />Method <br />Screenina ®flet <br />Trackidg Sheet (Wn) <br />r <br />SPOILS <br />Storage Method <br />contamination Noted - yes/no <br />Storage Locationkg,,t-,tL1Lj <br />Distance to\ <br />Domestic wel <br />If yes, locA <br />GROUTING <br />line <br />site - yes/no <br />& distance - <br />N <br />Well No. <br />Total Depth n� <br />Screen Length �Q ` <br />Filter Pack 3' <br />Bentonite Pellets _3' <br />Grout <br />Completion -Stove pip Christie box <br />Auger O.D. _ <br />Auger I.D. a� <br />MATERIALS USED: <br />Depth to water S' _ - Casing type VC- -q <br />Mix Ratios 1.1k o®��� ® -� (fir G� �� f� Blank ® ft. Screen o ft. <br />f <br />Installation Method Kaci Slot size dJ_C. <br />Quantity Installed Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />Total Billed Time Per Site f- .�® <br />Date Permit Finalized <br />