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MONITORING WELL INSTALLATION REPORT <br />Date: �d <br />Premise Address: <br />Well No.: <br />Inspector: LL,!j <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 <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 />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 />height <br />I 4vFf,71 ' 4 <br />L�Mli <br />A80VE-GACUND <br />COMPLFrCN <br />eF, AV- r <br />• <br />Ground Surf act <br />grout <br />ft. <br />it. ft. <br />0 <br />-- r <br />dorsi = c <br />sacicn <br />qnVW Pack <br />ft. <br />MATERIALS/DEVEI.OPMENT <br />Casing type <br />ft. <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 />