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MONITORING WELL INSTALLATION REPOR i <br />Date: <br />Premise Address: <br />Well No.: Al W /3 <br />Inspector: <br />Permit No. <br />Drilling Company: <br />Driller: <br />Consultant <br />Geologist <br />SPECIAL PERMIT INFO. <br />5� <br />Distance to sewer line <br />Domestic well on site - ( y / n ) <br />If yes, location and distance - <br />5r� <br />5M <br />SAMPLING <br />Holding Temperature <br />Method <br />Screenin; Method S <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 6. <br />Screen Length (from) `( (to) " <br />Filter Pack (from) (to) <br />Bentonite (from) (to) <br />Grout (from) (to) <br />Drilling rig type <br />Auger O.D. I.D. <br />Completion - Stove pipe/christie box (circle one) <br />casing <br />height <br />ABCVE-GACUND <br />COMPLET CN CHMM-80X <br />COMPLETION <br />Ground Suriacs <br />grout <br />ft. <br />tt. <br />M <br />_ O <br />ilorai c <br />socicn _ <br />gnyw POCK <br />ft. <br />Casing N( -- <br />Blank ft. Screenu ft. <br />Slot size 2 t� <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 method <br />