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Date: <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 />GROUTTNG <br />Depth to water <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />EH 29 29 <br />MONITORING WELL INSTALLATION REPORT <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/cli ristie box (circle one) <br />casing <br />height <br />1 7MI, '4 <br />ABOVE-GRCUND CHR* Y -80X <br />OOkFLETION COMALEMN <br />G=nd Such s <br />9raR <br />tt. <br />. tt. <br />ft. <br />rY —_ <br />0 <br />socicn <br />�: �,rsvol pack <br />A _ <br />�.........ft. M <br />MATERIALS/DEVELOPMENT <br />Casing type <br />Blank fL 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 />