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MONITORING WELL INSTALLATION REPOn`r <br />Date: 9WI / -3 —2--5 10 <br />Premise Address: <br />W <br />Well No.: <br />Inspector: --� ,— <br />Permit No. <br />Drilling Company:. <br />Driller: l <br />Consultant <br />Geologist 1� <br />SPECIAL PERMIT INFO. <br />? <br />Distance to sewer line T� <br />Domestic well on site - ( y O <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 <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />EH 29 29 <br />3-2--5- ) o /U.u14 <br />CONSTRUCTION <br />Total Depth 15 C) <br />Screen Length (from) 0,5 (to) .2-5.57 <br />Filter Pack (from) sV (to) z i <br />Bentonite (from) 2 (to) 14 <br />Grout (from) iq (to) a <br />Drilling rig type C tl� 7-5 <br />Auger O.D. 14D I.D. <br />Completion - Stove pipe/christie box (circle one) <br />casing <br />height <br />grout <br />to ft. <br />21 ft. <br />MATERIALS/DEVELOPMENT <br />Casing type 4 Sj"_ 4b �� 0_ <br />Blank %'E' �— ft. Screen ZS ft. <br />Slot size .nom <br />Bags cement <br />Buckets bentonite U604 - <br />Bags sand/gravel 1100 .�— <br />Filter Pack type/size 3 <br />Surge Block: -(3y/n <br />Discussed with geologist: - ( y <br />Type of method _ <br />