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q <br />MONITORING WELL INSTALLATION REPORT <br />Date: <br />Premise Address: zy l ' <br />Well No.: D'u" <br />Inspector:""R-� <br />Permit No. <br />Drilling Company: <br />Driller: <br />Consultants e�1 <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 />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 />U RJ— <br />CSS - 7i73-10 <br />Case. <br />CONSTRUCCION <br />�sG z �11R Fl G <br />Total Depth U , <br />Screen Length (from)(to) <br />Filter Pack (from) (to) <br />Bentonite (from)1j—(t <br />Grout (frol.— (to) <br />Drilling rig type <br />Auger O.D. I.D. <br />Completion - Stove pipe/christie box (circle one) <br />7f <br />'� 1 F-11 I 'd <br />A80VE-GACUN0 <br />COMPLETION <br />ca <br />he <br />G <br />slot'.ai <br />socicn <br />ft. <br />MATERIALS/DEVELOPMENT <br />Casing type 2- ITU Ci <br />Blank $ Y ft. Screen ft. <br />Slot sizeo . 0 Zd <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/ ' e -V►° <br />Surge Block: - 6%' ti ) <br />Discussed with geologist: - / n ) <br />Type of method <br />