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0 <br />'PONITORING WELL INSTALLATION REPOI-t 1 <br />Oate: 3 ' z 3' IC7 3 f y��lL <br />Premise Address: ON&' <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 />GROUTING <br />Depth to water <br />MixRatios <br />Installation Method ltge4t-t 'e' <br />Quantity Installed <br />EH 29 29 <br />CONSTRUCTION <br />Total Depth,_ <br />Screen Length (from) 2 rZfe- -(to) '5372 - <br />Filter Pack (from) Zlo (to) I <br />Bentonite (from) 23 (to) 7 <br />Grout (from) V> _(to) 0 <br />Drilling rig type oSE If <br />Auger O.D. /0 I.D. <br />Completion - Stove pipe/christie box (circle one) <br />casing <br />height <br />ABOVE -GROUND <br />COMPLETION <br />200--ift. <br />Ground Surface <br />9flolt <br />slottedtecdon <br />VivW pack <br />ft. <br />MATERIALS/DEVELOPMENT <br />Casing type <br />Blank ft. Screen 2-5 <br />Slot size <br />Bags cement <br />Buckets bentonite /60 <br />Bags sand/gravel Olt <br />Filter Pack type/size 03 <br />Surge Block: - ( y /( n <br />Discussed with geologist: - (y/n) <br />Type of method_ <br />r <br />ft. <br />