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MONITORING WELL INSTALLATION • ORT <br />Date: � L? Lm <br />Premise Address: ) . <br />Well No.: <br />Inspector: 11 <br />Permit No. <br />Drilling Company: <br />SPECIAL PERMIT INFO. <br />Distance to sewer line <br />Domestic well on site - ( y / n ) <br />If yes, location and distance - <br />SAMPLING __V � <br />P <br />Holding Temperature 7 C <br />Method <br />Screening Method <br />Tracking Sheet - ( y / n ) <br />SPOILS /'J/A 5 <br />0 <br />Storage Method <br />Contamination Noted - ( y / n ) <br />Storage Location <br />GROUTING <br />Depth to water <br />Mix Rados <br />Installation Method <br />Quantity Installed <br />EH 29 29 <br />P. <br />S 1&4W734 <br />CONSTRUCTION <br />�fi�UV 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 />F height <br />ABOVE-GSCUND <br />COMPLETION <br />31 <br />VXYd Pack <br />h. <br />M�£RIALS.OPMENT <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 />