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Date: el 6 <br />Premise Address: <br />Well No.: <br />Inspector• <br />Permit No. 12& <br />Drilling Company: <br />Driller: <br />Consultant <br />Geologist Q� <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 />MONITORING WELL INSTALLATION REPORT <br />CONSTRUCTION <br />Total Depth 8 � .' <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/clu-istie box (circle one) <br />— '[7 casing <br />fr <br />ofj he; <br />AZCVE-GACUND <br />COMPLETION <br />MATE RI ALS/DEVE LOP MENT <br />Casing type )'I pVU <br />Blank ft. Screen ft. <br />Slot size n . y w <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />Surge Block: - ( y / ii ) <br />Discussed with geologist: - ( y / n ) <br />Type of method <br />O <br />_ <br />p�avd pads <br />MATE RI ALS/DEVE LOP MENT <br />Casing type )'I pVU <br />Blank ft. Screen ft. <br />Slot size n . y w <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />Surge Block: - ( y / ii ) <br />Discussed with geologist: - ( y / n ) <br />Type of method <br />