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*04/ PAGAW4 _OF <br /> MONITORING WELL INSTALLATION REPORT <br /> T <br /> Date: �^V�1 .\ CONSTRUCTION � ' 1 <br /> Premise Address:-:i vl/ ( ,sW� Well No. in W <br /> I�ns�cnec`or: Total Depth <br /> Screen Length S <br /> Filter Pack <br /> Bentonite Pellets <br /> Permit No. Grout <br /> Consultant CoG Completion-Stove pipe/ ristie bo <br /> Geologists^—lam <br /> Auger O.D. <br /> Auger Z.D. <br /> SAMPLING <br /> ,,, <br /> F.oldcng emperature $dck-up <br /> Met:o <br /> —EWTScreening Method <br /> A3CVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) CC�'�`TION COMPLETION <br /> SPOILS Ground Sumacs <br /> grout <br /> Storage Method <br /> Contamination Noted - yes/no �P <br /> Storage Location ft <br /> a <br /> SPECI.AL PERMIT INFO. — c. <br /> 0 <br /> slotted — c <br /> Distance to sewer line socdan = 8 <br /> Dcmestic well on site - ves/no I <br /> IP ves, location & distance - — Pack <br /> y� <br /> ( L <br /> GROUTING irI b <br /> i � U MATERIALS USED: <br /> De?C: to water v• Casing type <br /> Mix Ratios P. Blank _ ft. Screen�b tet. <br /> Installation Method Slot size <br /> 1.uantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Dare Permit Finalized I �� <br />