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'--MONITORiNG WELL INSTALLATION REPORT <br />Date: /i'// ? Id h <br />Premise Address: <br />Well No. / <br />Inspector. �✓� <br />Permit No. <br />Drilling Company: <br />Driller: <br />Consultant _ <br />Geologist L//•Z e"- C/ <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 />'4 <br />ABOVE -GROUND <br />COMPLETION <br />tt. <br />cloned <br />tockn <br />Ground Surface <br />MATERIALS/DEVEi.OPMENT <br />Qrcut <br />ft. <br />31 <br />lnv,w Pack <br />Casing type <br />Blank 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 />