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r <br />MONITORING WELL INSTALLATION REPORT <br />%1/02_ <br />Date: dZ <br />Premise Address: 4,1 a) <br />Well No.: l ,I/ <br />Inspector. <br />Permit No. <br />Drilling Company: <br />Driller: <br />Consultant <br />Geologist T <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 />Filter Pack (from) <br />(to) <br />Bentonite (from) <br />(to) <br />Grout (from) <br />(to) <br />Drilling rig type <br />Auger O.D. <br />I.D. <br />Completion - Stove pipe/cluistie box (circle one) <br />casing <br />he; <br />A8CV-GACUND C iRZ7Y-BOX <br />COWLETCN COMR—EnCN <br />Ground Suiaas <br />grout <br />ft. <br />ft. <br />ft. <br />= a <br />tockn —' <br />VAY9i Pack <br />MATERIALS/DEVELOPMENT <br />Casing type <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 / n ) <br />Discussed with geologist: - ( y / n ) <br />Type of method <br />