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MONITORING WELL INSTALLATION REPORT <br />Date <br />Premise Address: <br />Well No.: <br />Inspector: <br />Permit No. <br />Drilling Company: <br />Driller: <br />Consul <br />Geolo <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 />Mix Ratios <br />Installation Method <br />Quantity Installed <br />EH 29 29 <br />CONSTRUCTION <br />Total Depth <br />Screen Length (from) <br />(to) <br />Fijter Pack (from) <br />(tC) <br />Bentonite (from) <br />(to) <br />Grout (from) <br />(to) <br />Drilling rig type <br />Auger O.D. I.D._ <br />Completion - Stove pipe/christie box <br />(circle one) <br />casing <br />Iheight <br />ABOVE -GROUND <br />CChFL TCN C--RZTY-8070 <br />COMPLETION <br />Gr;xmd Saiaca <br />9rout <br />ft. <br />ft ft. <br />= m <br />o <br />= m <br />s to ttad —" c <br />gavel Fac�< <br />MATERIALS/DEVELOPMENT <br />Casing type <br />Blank 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 <br />Type of method_ <br />Screen ft. <br />- ( y / n ) <br />