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MONITORING WELL INSTALLATION REPORT <br />Date I/Y— I 11f% /' Q <br />Premise Address: 3c-?/�1/ W • � �¢�L l,&Y,-� <br />Well No.: <br />Inspector: <br />Permit No. <br />Drilling Company:[' ( Q -u-(./ <br />Driller: <br />Consultant "6 n et5 <br />Geologist <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 />GROUPING r ;� <br />Depth to water <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />EH 29 29 <br />CONSTRUCTION s� <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 />I n�T <br />height <br />ABOVE -GROUND <br />COMPLETION <br />.001ii <br />INS <br />a <br />Ground Surface <br />grout <br />ft. <br />ft. <br />q <br />C <br />O <br />slottad = c <br />Bacton <br />Ignv+ Pack <br />ft. <br />MATERIALS/DEVELOP MENT <br />ft. <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: - ( y / n ) <br />Type of method <br />