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Premise Address: <br />CONSTRUCTION <br />Total Depth <br />Holding Temperature <br />Method <br />Installation Method <br />Quantity Installed <br />EH 29 29 <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />Surge Blodc: - <br />Discussed with geologist: - ( y/ n) <br />Type of method <br />MONITORING WELL INSTALLATION REPORT <br />Well No.: <br />Inspector: <br />Permit No. <br />Drilling Company: <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 />SPOILS <br />Screening Method <br />Tracking Sheet -(y/ n) <br />Date: <br />Depth to water <br />Mix Ratios <br />Screen Length (from) • (to) <br />Filter Pack (from) (to) <br />Bentonite • _ (from) (to) <br />Grout (from) tto) <br />Drilling rig type . <br />Auger O.D. I.D. <br />Completion - Stove pipe/christie box (circle one) <br />casing <br />height <br />C4-0:11STY-p0X <br />COMPLETION <br />Blank ft. Screen <br />Slot size <br />Storage Method <br />Contamination Noted - ( y / n) <br />. Storage Location <br />GROUTING <br />MATERIALS/DEVELOPMENT <br />Casing type <br />ft. <br />Bags cement