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—i'GE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: W �yv CONSTRUCTION <br /> Premise Address: IBJ u Well No. W ' <br /> Inspector: Total Depth <br /> V L J Screen Length <br /> ff <br /> Filter Pack —7 U <br /> ��11 Bentonite Pellets <br /> Permit No. V / Grout V —*5 0 <br /> Consultant Completion-Stove pipe ch�istie bo <br /> Geologist <br /> Auger O.D. <br /> Auger I.D. (o <br /> SAMPLING ----- -- -- __-- <br /> Holding Temperature ¢°� stk*-up <br /> Method B(�� <br /> I � T <br /> Screening Method r7 /�'( —cmT <br /> ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet 0n) COMPLETION <br /> COMPLETION <br /> Ground Surface <br /> f;yr SPOILS <br /> grout <br /> Storage Method d2i <br /> 7/ 1 <br /> Contamination Noted yes no �' <br /> Storage Location <br /> aj So <br /> _ <br /> CD <br /> q <br /> (P <br /> SPECIAL PERMIT INFO. - = <br /> = o <br /> slotted = <br /> Distance to sewer line section "- <br /> Domestic well on site - ye no _ gravelpack <br /> If yes, location & distance <br /> n, <br /> GROUTING <br /> MATERIALS USED: <br /> JDepth to water Casing type ` v 'fV l� Ci <br /> Mix Ratios Blank ft. Screen ft. <br /> Installation Method Slot size x•112.1) <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 '1 5 D ' <br />