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MONITORING WELL INSTALLATION REPORT <br />Date:_ - ��� �� Z - <br />Premise Address:_ <br />Well No.: <br />Inspector. <br />Permit No._2e,�, <br />Drilling Company:_ <br />Driller: <br />Consult t <br />Geologist <br />SPECIAL PERMIT INFO. <br />Distance to sewer line <br />Domestic well on site n ) <br />If yes, location anistance - <br />SAMPLING <br />Holding Temperature <br />Method <br />Screening Method <br />Tracking Sheet - ( y / n ) <br />SPOILS <br />Storage Method' - Q c(Ntux, <br />Contamination Noted - ( y n <br />Storage Location C',n Sf <br />GR— O�\_G <br />Depth to water <br />Mix Ratios^�7 <br />Installation Method <br />Quantity Installed �v <br />EH 29 29 <br />CONSTRUCTION <br />Total Depth <br />Screen Length (from) <br />(to)_�_ <br />Filter Pack (from) <br />(to)__ <br />Bentonite (from) <br />(to)�_ <br />Grout (from) <br />(to)__ <br />Drilling rig type <br />_ <br />Auger O.D. _ I.D. <br />Completion -Stove pipe/cliristie box (circle one) <br />casing <br />0 he_ght <br />A3CVE-GACQND <br />CCNVLLTICN <br />r—' , 4 C-4 <br />U1 <br />CHA:S7Y-30X <br />COMPL_mcN <br />prccrt <br />RioCa <br />soden <br />�rarrn� Facft <br />n. <br />MATERIALS/DEVELOPMENT <br />Casing type L (' V(` <br />Blank ft. Screen <br />Slot size <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />Surge Block: - ( y / Il ) <br />Discussed with geologist: - ( y/ n ) <br />Type of method <br />