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PAG.�%�OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: 6I 2J I ort CONSTRUCTION <br /> Premise Address: < 1 �� ` Well No. <br /> Ins.ector' Total Depth S <br /> Screen Length '- <br /> Filter Pack <br /> Bentonite Pellets <br /> Permit No. Grout <br /> Consultant Completion-Stove pipe/ch•-. a box <br /> Geologist_��r�,n i ArA &�-Z <br /> Auger O.D. -T <br /> �S) Auger I.D. <br /> SAMPLING to L d/`' <br /> a <br /> Folding Temperature ( t sock-up � <br /> Met::od `� (� +� �T <br /> 77— <br /> Screening Method <br /> 1.BOVE-GRCUND <br /> Tracking Sheet (y/n) SNP!Fi,aN CMSTY-BON <br /> PLETICSPOILS Ground Surfaes <br /> grout <br /> Storage Method 3 <br /> Contamination Noted - yes/no 3 <br /> Storace Location 26 <br /> n <br /> 0 <br /> SPECIAL PERMIT INFO. = s <br /> c. <br /> o <br /> sloned — c <br /> Distance to sewer 1'_ne soon $ <br /> Domestic well cn site - ves/no <br /> If ves, location & distance - <br /> va",Pack <br /> IE <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type 2 I C— <br /> Mix Ratios Blank <br /> _36— ft. Screen ;10 ft. <br /> Installation Method Slot size <br /> Qua nti`_v :rstalled Bags cement <br /> Buckets be..^.tonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />