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'`/ PAG*J _OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: l� CONSTRUCTION r I^W1 <br /> Premise Address: O I �" k�.1' " Well No. \`r <br /> Ins--ector: Total Depth 3 .S <br /> l7 Screen Length -,JL'r, <br /> Filter Pack <br /> Bentonite Pellets <br /> Permit No. Grout <br /> Consultant — Completion-Stove pipe/christie box <br /> Geologist ly\AA4,-- aw2 c-- <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING <br /> Folding Temnerature <br /> Method 7 <br /> Screening Method <br /> ABOVE-GRCUND <br /> Tracking Sheet (y/n) CCNVL`TCN CCMPL°TION <br /> Ground Surtae0 <br /> SPOILS <br /> r U,yr�5 grout <br /> Storage Method <br /> Contamination Noted - yes/no ft. <br /> Storace Location AO <br /> ft I_ <br /> e <br /> SPECIAL PERMIT INFO. — c_ <br /> 0 <br /> slotted — c <br /> Distance to sewer line as=on <br /> Domestic well on site - yes/no <br /> I: yes, location & distance <br /> i <br /> GROUTING <br /> MATERIALS USED: <br /> rr C <br /> Depth to water Casing t oe fV <br /> Mix Ratios Blank -� Ft Screen ID `t. <br /> 1-stallation Method Slot size �; �J <br /> Quanti_r _nstalled Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel C,a,, u <br /> __-ter Pack -,,,,pe/size (J <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />