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\./ PAGi,�OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: ` .' �^ CONSTRUCTION t� <br /> Premise Address:\1 k�u ' - Well No.� y <br /> Inspector: Total Depth <br /> Screen Length <br /> Filter Pack /1Jdlwv� Q <br /> Bentonite Pellet <br /> Permit No. Grout <br /> Consultant t-7Completion-Stove pip Christie box <br /> Geologist r4pAAe, i <br /> U Auger O.D. <br /> Auger I.D. <br /> SAMPLING <br /> �ctickup <br /> ^01d �._ng emperdtlre <br /> Method i � � <br /> Screenne Method <br /> ABOVE-GRCUND CHRISTY-SOX <br /> Tracking Sheet (y/n) CCMPL-TION <br /> SPOILS Grpurd Surixe <br /> grout <br /> Storage Method _ �/' n <br /> Contamination ?Toted - y� no S'12 n. <br /> Storace Location If1 ft <br /> _ .3 <br /> e <br /> SPECIAL PERMIT INFO. — c. <br /> 0 <br /> = $Distance to sewer line alottadtanoo <br /> Domestic well on site - yes/no <br /> is yes, location & distance - _ qM%-WFack <br /> 3S <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing ;ype <br /> Ratios Blank ft Screen a. <br /> Installation Method Slot size 10,60 <br /> Quantity T_nstalled Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack tv )e/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />