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3E—OF <br /> t— <br /> MONITORING WELL INSTALLATION REPORT <br /> ���1�UC7�r CGt '115 _ y0 <br /> Date: jZ CONSTRUCTION <br /> Premise Address:0-70:9"41,q� Well No. I v l l �— <br /> Inspector• Total Depth 75 / <br /> Screen Length a5- 75 <br /> Filter Pack 7c,- ,60 <br /> �}r� Bentonite Pellets 60 - 5� <br /> Permit No. /� " 3 Z Grout S 9- <br /> Consultant_ 119G11;( Completion-Stove pipe/ ristie box <br /> Geologist �-3' � <br /> Auger O.D. <br /> Auger I.D. <br /> SAMPLING / <br /> stick-up <br /> Holding Temperature <br /> Method I <br /> T <br /> T <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 n. <br /> Storage Location <br /> O <br /> SPECIAL PERMIT INFO. = o <br /> slotted = c <br /> Distance to sewer line section = <br /> Domestic well on site - yes/no = gra Pack <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: I� <br /> Depth to water Casing type V <br /> Mix Ratios Blank ft. Screen ft. <br /> Installation Method Slot size <br /> Quantity Installed O Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized �L✓ �� C ����/ � <br />