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"MONITORING WELL INSTALLATION REPORT <br />Date: '9Z. <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, Iocation and distance - <br />SAMPLING <br />Holding Temperature <br />Method <br />Screenin; Method <br />Tracking Sheet - ( y / n ) <br />SPOILS <br />Storage Method <br />Contamination Noted - ( y / n ) <br />Storage Location <br />GROLUING <br />Depth to water <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />EH 29 29 <br />CONSTIt.UCTION <br />Total Depth <br />Screen Length (from) (to)�._ <br />Filter Pack (from) (to) <br />Bentonite (from) (to)� - <br />Grout (from) <br />Drilling rig type <br />Auger O.D. I.D. <br />Completion - Stove pipe/cluistie box (circle one) <br />casing <br />height <br />A80VE-GRCUND CHR=Y-BOX <br />COIFLETION COMPLEi1ON <br />G=r d 5ufact .....e <br />gfom <br />ft. <br />. ft. <br />¢� M <br />- Q <br />slorad <br />sodcn <br />— ¢aVW pack <br />�..,._._ft. <br />tar-- IF It. <br />MATERIALS EVEI.OPMENT <br />Casing type <br />Blank fr. 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 />