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MONITORING WELL INSTALLATION REPORT <br />Date: (,/ _/(' ;rc <br />Premise Address: m <br />Well No.: IA' 1 I LA <br />Inspector: I <br />Permit No. f <br />Drilling Company: rav <br />Driller:j�,, � <br />leL� <br />Consultant - <br />Geologist <br />SPECIAL PERMIT INFO. <br />Distance to sewer line twk <br />Domestic well on site - ( y / n ) <br />If yes, location and distance - <br />SAMPLING <br />Holding Temperature 7� <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 <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) (to)LLLi <br />Filter Pack (from) (to) <br />Bentonite (from) Z (to) C <br />Grout (from) C (to) S u� <br />Drilling rig type <br />Auger O.D. 8 I.D. <br />Completion - Stove pipe/cliristie box (circle one) <br />casing <br />height <br />7,11 <br />ABCVE-GROUND CHRZTY-80X <br />COMPLETCN COMPLEnCN <br />Grourd Surf acs..6 <br />sectcn <br />MATERIALS/DEVEI.OPMENT <br />grout <br />.31 <br />gnV1W panic <br />// <br />Casing e H� <br />Blank VC ft. Screen Z O ft. <br />Slot size D _ 02 tU <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/ <br />Surge Block: - ii ) �� <br />Discussed with geologist: - U Y 4 n ) <br />Type of method <br />