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MONITORING WELL INSTALLATION REPOR i <br />Date: 2 I b I bo <br />Premise Address: 36 ' ti►-"� �+ <br />Well No.: D <br />Inspector: vw1� <br />Permit No. "^ <br />Drilling CompanyA V 11�-d <br />Driller: <br />Consultant dC-� <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 />d <br />Holding Temperature <br />Method <br />Screening Method <br />Tracking Sheet - ( y / n ) <br />SPOILS(I- <br />Storage Method <br />Contamination Noted - <br />Storage Location 5-� <br />GROUTING <br />Depth to water Ss <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />EH 29 29 <br />CONSTRUCTION <br />Total Depth 4 [ ' <br />57 1 <br />Screen Length (from) (to) <br />Filter Pack (from) (to) 5 <br />Bentonite (from) (to) o .S <br />Grout (from) `I- o ti� (to) <br />Drilling rig type t,ML `LS <br />Auger O.D. T" I.D. G <br />Completion - Stove pipe/cliristie box (circle one) <br />ca <br />height <br />ABOVE-GRMNO <br />COWLETICN <br />c. <br />y0 <br />S ft. <br />.. <br />1 <br />ft. <br />MATERIALS/DEVELOPMENT <br />Casing type �_JIrvc"' <br />Blank ft. Screen zd ft. <br />Slot size d <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel 7'0 00 <br />-11 <br />Filter Pack type/ ' e <br />Surge Block: - y / ii ) <br />Discussed wit eologist: -gl n ) <br />Type of metliod �/ <br />S ft. <br />glorgd <br />'— <br />socicn <br />gfaY�I paCK <br />ft. <br />MATERIALS/DEVELOPMENT <br />Casing type �_JIrvc"' <br />Blank ft. Screen zd ft. <br />Slot size d <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel 7'0 00 <br />-11 <br />Filter Pack type/ ' e <br />Surge Block: - y / ii ) <br />Discussed wit eologist: -gl n ) <br />Type of metliod �/ <br />