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4 'AGF OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: - 1� CONSTRUCTION <br /> Premise Address: 2, cD Well No. <br /> Inspector: Total Depth <br /> Screen Length X6 <br /> Filter Pack S0 ' S S <br /> Bentonite Pellets <br /> Permit No. Grout .SZ`— ' <br /> Consultant Completion-Stove pipe/christie box <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING <br /> Holding Temperature stJdt-up <br /> Method <br /> Screening Method <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y/n) COMPLETION COMPLETION <br /> Ground Surface <br /> SPOILS <br /> grout <br /> Storage Method <br /> Contamination Noted - yes/no »' <br /> Storage Location ft. <br /> ft. <br /> = a <br /> SPECIAL PERMIT INFO. <br /> aloft" _ c <br /> Distance to sewer line section _ <br /> Domestic well on site - yes/no = gravel pack <br /> If yes, location & distance <br /> ft. If LEE ft. <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water Casing type <br /> Mix Ratios Blank ft. Screen ft. <br /> Installation Method Slot size <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />