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MONITORING WELL INSTALLATION REPORT <br />Date: !O�Lo D <br />Premise Address: 3�) it/ <br />Well No.: S" <br />Inspector: <br />Permit No. <br />Drilling Company: <br />Driller: <br />Consultant S 610A <br />Geologist_ /071-111 <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 />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 />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/cliristie box (circle one) <br />casing <br />height <br />ABOVE-GRCUND <br />COMPLETION <br />Ground Surfacs <br />Grout <br />ft. <br />ft. <br />- M <br />O <br />tloroi _ � <br />soden —_ <br />gavel Pack <br />...ft. =F ft. <br />MATERIALS/DEVELOPMENT <br />Casing type _ <br />Blank ft. Screen ft. <br />Slot size <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />Surge Block: - ( y / n ) <br />Discussed with geologist: - (Gy / n ) <br />Type of method <br />