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"MONITORING WELL INSTALLATION REPOKT <br />Date: J Z %6 <br />Premise Address: <br />Well No.: <br />Inspector: <br />Permit No. <br />Drilling Company: <br />Driller: <br />Consultant <br />Geologist <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 />GROLMNG <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), (to), <br />Filter Pack (from) (to)-, -- <br />Bentonite (from) (to) <br />Grout (from) (to) <br />Drilling rig type <br />Auger O.D. I.D. <br />Completion - Stove pipe/ciu istie box (circle one) <br />casing <br />Theight <br />4 <br />_ T <br />A$OVE-GFiL�CMD Ci•W�S'TY�OX <br />co t.�r�orr conPtmaN <br />Ground Su�aes -•t <br />gtcui <br />. It. <br />V0. m <br />5� O <br />G <br />tlornd v = e <br />&ocicn <br />gmvw Pack <br />MATERIALS[DEVELOPMENT <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 />