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MONITORING WELL INSTALLATION REPOR i <br />Date: 76 ) <br />Premise Address: <br />Well No.: L{ 1LiW/D�� Jf <br />Inspector• <br />Permit No. /� Q <br />Drilling Company:_( ae__ �- <br />Driller: <br />Consultant <br />Geologist <br />SPECIAL PERMIT INFO. <br />Distance to sewer line &-V� <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 />5�7pt ^'W,� 64�- <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 />—f 7— height <br />ABOVE-GRCUND <br />CCNPLET10N <br />Orourd Suriacs <br />grout <br />-7�1 S - ft. <br />f�2 � �. • � ft. <br />0 <br />�,f1YYi FaIC�C <br />MATERIALS/DEVELOPMENT <br />Casing type PIC- <br />Blank <br />VGBlank ft. Screen ft. <br />Slot size o Z - <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/siz 3 <br />Surge Block: - ( y / n ) <br />Discussed with geologist: - ( y / n ) <br />Type of method <br />g,,� P01-11-1111. <br />