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MONITORING WELL INSTALLATION REi uRT <br />Date: /J /�o/ <br />Premise Address: G.i e--'C-7� 64t"e <br />Well No.: <br />Inspector: <br />Permit No. <br />Drilling Company: <br />Driller: �( <br />Consultan <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 />a <br />Holding Temperature C <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 15 <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/christie box (circle one) <br />casing <br />7— height <br />PTA <br />ABCVE-GACUND CNASSTY-BOX <br />CCkFLErKDN COMPLEnCN <br />Ground Surfacs <br />grout <br />ft. <br />� ft. <br />0 <br />— C <br />O <br />flor*d f = <br />socicn <br />9MVo1 Pack <br />MATERIALS/DEVELOPMENT <br />Casing type <br />Blank ft. Screen 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: - ( y / n ) <br />Type of mediod <br />