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MONITORING WELL INSTALLATION REPO <br />Date: 5 -20 -OF <br />I� d <br />Premise Address: <br />Well No. <br />Inspector: �J / <br />Permit No. <br />Drilling Comp <br />any: 9'LC <br />Driller: '��^ <br />Consultant ri . <br />Geologist <br />SPECIAL PERMIT INFO. <br />Distance to sewer line L- , <br />Domestic well on site - ( y / n ) <br />If yes, location and distance - <br />SAMPLING <br />Holding Tempertature tl C <br />Method [� <br />Screening Method <br />Tracking Sheet - ( y / n } <br />SPOILS <br />Storage Method 5S <br />Contamination Noted - y n ) <br />Storage Location 0D� - - <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) (to) <br />Filter Pack (from) (to) <br />Bentonite (from) (to) <br />Grout (from) (to) <br />Drilling rig type <br />Auger O.D. /Q I.D. <br />Completion - Stove pipe/christie box (circle one) <br />casing <br />height <br />ABOVE -GROUND <br />OOMPLETION�- : • <br />I <br />Ground Surface +��� <br />grout <br />� <br />..Z..�:. ft. <br />�ft. <br />ft. <br />W <br />C <br />$totted <br />an - VavW Pack <br />ft. <br />MATERIALS/DEVELOPMENT <br />Casing type ..,?- a <br />Blank_ 7 ft. Screen <br />Slot size • dl0 " <br />Bags cement �-- <br />Buckets bentonite <br />Bags sand/graveI /DSO _ <br />Filter Pack type/size <br />Surge Block: - ( y 49D' <br />Discussed with geologist: - ( y./,—n) <br />` <br />Type of method <br />