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GE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: 1' l� L' CONSTRUCTION <br /> Premise Address:_ `^�' l�� U Well No. 3 G <br /> Inspector: sz, Total Depth 5 <br /> 1. Screen Length 65_1K <br /> Filter Pack $O -'75 <br /> Bentonite Pellets -5 <br /> Permit No. Grout 0 - <br /> Consultant Wc A Completion-Stove pipe/ ristie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING q <br /> tuck up <br /> Holding Temperature <br /> Method <br /> Screening Method ,. <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) COMPLETION COMPLETION <br /> Ground Surface <br /> SPOILS <br /> proof <br /> Storage Method rOX46�-' <br /> n. <br /> Contamination Noted - es no <br /> n. <br /> Storage Location <br /> o <br /> SPECIAL PERMIT INFO. o <br /> ` slotted <br /> Distance to sewer line ` taction = <br /> Domestic well on site - yes o gravelPa& <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: p <br /> Depth to water � �� Casing ty�e P <br /> Mix Ratios Blank � ft. Screen ft. <br /> Installation Method Slot size © '1D <br /> CA <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size 3 <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />