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T 0NITOPJNG WELL INSTALLATION REPOnT <br />Date:��������� <br />Premise Address: <br />Well No. <br />Inspector: <br />Permit No. <br />Drilling Company: r�' �— <br />Driller: � <br />I IJ <br />Consultant <br />1 <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 />GROUTING <br />Depth to water =36 <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />EH 29 29 <br />CONSTRUCTION <br />Total Depth 6 <br />Screen Length (from) :5-7 2 (to) 2,2 Y2— <br />Filter Pack (from) (00 (to) Z <br />Bentonite (from) 2' (to) —z I <br />Grout (from) Z- (to) b <br />Drilling rig typed %S <br />Auger O.D. 12 I.D. <br />Completion - Stove pipe/christie box (circle one) <br />casing <br />height <br />ABOVE -GROUND <br />COWFLEf ION <br />MATERIALS/DEVELOPMENT <br />Casing type `f <br />Blank ft. Screen ft. <br />Slot size .020 <br />Bags cement <br />Buckets bentonite_ <br />Bags sand/gravel <br />Filter Pack type/size <br />Surge Block: -O n) a <br />Discussed with geologist: - ( y / n ) <br />Type of method <br />3�- �,e�o 7�tuiS rJ <br />