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MONITORING WELL INSTALLATION REPORT" <br />Date: 1 <br />Premise Address: <br />Well No.: <br />Inspector• <br />Permit No. <br />Drilling Company: S A- �C <br />Driller: �(S ('�[ C6 - <br />Consultant <br />crn- <br />Geologist L,-14 <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 />Screenin; Method <br />Tracking Sheet - ( y / n ) <br />SPOILS <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 <br />Auger O.D. <br />I.D. <br />Completion - Sto've pipe/christie box (circle one) <br />casing <br />height <br />ABOVE-GRCUND <br />COMPLETION <br />.r.ft. <br />?90 ft <br />slor." <br />sacicn <br />OPT <br />31 <br />g" -W Pack <br />Storage Method MATERIALS/DEVELOPMENT <br />Contamination Noted - ( y / n ) <br />Storage Location Casing type N 1A <br />Blank ft. Screen ft. <br />d-� Via' Slot size <br />GROUTING �ji /10►��(! •c�•C Bags cement <br />F1114 �,� �on�p / a.b Buckets bentonite <br />Depth to water _ 5 u Bags sand/gravel <br />Mix Ratios Filter Pack type/size <br />Installation Method Surge Block: - ( y / n ) <br />Quantity Installed Discussed with geologist: - ( y / n ) <br />Type of method <br />EH 29 29 <br />