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'AGE OF - - <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: ` CONSTRUCTION <br /> Premise Address: 2 16A / )C- e Well No. In(-,I r-I L A 04- 12 <br /> Inspector: Total Depth_ Z v <br /> ' f Screen Length <br /> Filter Pack cJU - 3 <br /> 9 G Bentonite Pellets <br /> Permit No. ��_ ` 7o Grout 1Z- 0 <br /> Consultant t/L Completion-Stove pip Christie ox <br /> Geologist r- <br /> Auger O.D. <br /> Auger I.D. 6 �� <br /> SAMPLING - — -- -- <br /> Holding Temperature atldc-up <br /> Method <br /> CO/% 71/10/o 1/5 l'o/ C_ T <br /> Screening Method <br /> lo� AEj;VE-GROUND CHRISTY-BOX <br /> Tracking Sheet (y6d COMPLETION COMPLETION <br /> Ground Surlace <br /> SPOILS <br /> DQ proal <br /> Storage Method or -4111'LS <br /> Contamination Noted - yes/no n. <br /> n. <br /> Storage Lo/cation <br /> cy'? <br /> m <br /> SPECIAL PERMIT INFO. u <br /> slotted = c <br /> Distance to sewer line vection <br /> Domestic well on site - yesLn = gravWpack <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> G ' yL <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 l��• 'S ���� ��v�oj�s� G✓�5 re�� <br /> Date Permit Finalized �LJ' /�/' G��y/l o�✓v�S <br />