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.rtJNITORING WELL INSTALLATION REPO, <br />Date: �/ I <br />Premise Address: <br />Well No.: <br />Inspector: <br />Permit No. <br />Drilling Company: <br />Driller: K'►� �� 60' /?-- <br />Consultant <br />Geologist LO -L 1 <br />SPECIAL_PERMIT INFO. <br />Distance to sewer line <br />Domestic well on site - ( y / n ) <br />If yes, location and distance - <br />SAMPLING <br />Holding Temperature <br />Method <br />Screening Method <br />Tracking Sheet - ( y / n } <br />SPOILS <br />Storage Method <br />Contamination Noted - ( y / n ) <br />Storage Location <br />GROUTING <br />Depth to water <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />EH 29 29 <br />CONSTRUCTION <br />Total Depth <br />Screen Length (from) <br />(to) <br />Filter Pack (from) <br />(to) <br />Bentonite (from) <br />(to) <br />Grout (from) <br />(to) <br />Drilling rig type <br />Auger O.D. <br />I.D. <br />Completion - Stove pipe/christie box (circle one) <br />casing <br />height <br />6T- <br />ABOVE-GRCUND <br />COIPI-ETION <br />K. <br />slored <br />socicn <br />� --tt. <br />Ground Sudws <br />ofeut <br />ft. <br />ft. <br />N.. <br />ao <br />• <br />y~ <br />O <br />=. <br />= <br />g rW Pack <br />MATERIALS/DEVELOPMENT <br />Casing type <br />BIank ft. Screen ft. <br />Slot size <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />Surge Block: - ( y / n } <br />Discussed with geologist: - ( y / n ) <br />Type of method <br />