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Date: y� 1 co <br />Premise Address: �� (A <br />Well No. pw N <br />Inspector: 4-k� <br />i' I"P �• . <br />Drilling Company: �Ctil�lt� <br />Driller: e,, <br />Consultant �Lcr\' <br />Geologist_ �- S <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 � ocl- <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 51 <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />EH 29 29 <br />MONITORING WELL INSTALLATION REPUecr <br />CONSTRUCTION / <br />l0 <br />Total Depth <br />Screen Length (from) <br />(to) <br />Filter Pack (from) <br />(to) Z <br />Bentonite (from) 3 <br />(to) <br />Grout (from) 3 0 <br />(to), <br />Drilling rig typ <br />Auger O.D. I.D. <br />Completion - Stove pipe/cliristie box (circle one) <br />casing <br />—f + he; <br />IV ,d <br />ABOVE -GROUND <br />COMPLETION <br />tlorvd <br />sec'!cn <br />Aft. <br />Ground Sumac* <br />grout <br />30 - ft. <br />l ft- <br />N.. <br />ti•' � O <br />gravw pack <br />MATERI ALS`D EVELOPME NT <br />Casing type T y ptk-� <br />Blank_31ft. Screen ft. <br />Slot size OZ() <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 />