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MONITORING WELL INSTALLATION REPORT <br />Date: <br />Premise Address: 2ol w' <br />Well No.: �40 11A <br />Inspector: <br />Permit No. <br />Drilling Company: <br />Driller: <br />Consultant <br />Geologist �'f� <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 />Screening 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 />T he, <br />ASCVE-GRCUND <br />CCNFLET{CN <br />(3rourd Sudwe <br />out <br />ft. <br />o.LL=.f2.IL Z ft. <br />— _ a <br />Y <br />O <br />•lot:vi r ""- c <br />:oc"icn — <br />B <br />gnvw pack <br />-L-Itt. <br />MATERIALS/DEVELOPMENT <br />Casing typ <br />M <br />Blank ins ft. Screen ft. <br />Slot size l • 02,0 <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel 3 :S <br />Filter Pack type/size <br />Surge Block: - K;/ ti ) <br />Discussed with geologist: - / n ) <br />Type of method <br />