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MONITORING WELL INSTALLATION REPUKT <br />Date: 3CONSTRUCTION <br />Premise Address: 1�� Total Depth <br />Well No.: <br />Inspector: <br />Permit No. <br />Drilling Company: <br />Driller: <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 />Holding Temperature l <br />Method <br />Screenin; 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 />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 />he; 7//, <br />� '4 <br />ABCV :-GacuND <br />COMPLETCN <br />Ground Surface <br />grout <br />ft. <br />_ o <br />O <br />tlor ed <br />toc'icn —' <br />>; gaud p.acfc <br />�..e.ft. <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 / ii ) <br />Discussed with geologist: - ( y / n ) <br />Type of method <br />