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MONITORING WELL INSTALLATION REPORT <br />106) Date: LI� <br />Premise Address: <br />Well No.: /C - <br />Inspector: <br />Permit No. <br />Drilling Company: ra/0 e -t <br />Driller: - <br />Consultant �� c <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 />GROUTING <br />Depth to water <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />EH 29 29 <br />CONSTRUCTION <br />Total Depth F1 <br />Screen Length (from) (to) <br />Filter Pack (from) (to) �. <br />Bentonite (from) o (to) 1 2 -° <br />Grout (from) 2 (to)� <br />Drilling rig type <br />Auger O.D. I.D. <br />Completion - Stove pipe/christie box (circle one) <br />casing <br />height <br />'b' '4 <br />ABOVE -GROUND <br />CONFLET{ON <br />Ground Surf acs +��.� <br />grout <br />73 "0 ft. <br />ft. <br />ft. <br />i.• � M <br />_ C <br />O <br />soricn <br />g"VW pack <br />L2 <br />MATERIALS/DEVELOPMENT <br />Casing type;- �V� <br />ft. <br />Blank J_` ft. Screen 5 ft. <br />Slot size O.0 Z b <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Packtype/ ' e <br />Surge Block: - y n ) <br />Discussed with geologist: - t/ n ) <br />Type of method <br />