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MONITORING WELL INSTALLATION R.EPvAT <br />Date: � � �e # <br />Premise Address: <br />Well No.: <br />Inspector: <br />Permit No. <br />Drilling Company: <br />Driller: <br />Consultant <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 Te perature y�C� <br />Method l n.c-^n i -J-) <br />Screening Method fh <br />Tracking Sheet - (�/ n ) <br />SPOILS -/ <br />Storage Method 6-k <br />Contamination Noted - ( y <br />Storage Location�krht <br />GROUTING <br />Depth to water 55 <br />Mix Ratios <br />Installation Method <br />Quantity Installed <br />EH 29 29 <br />CONSTRUCTION <br />Total Depth 65 <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/cliristie box (circle one) <br />Y_ casing <br />height <br />ABCVE-GaG(UND <br />CONFLETiCN <br />Ground Surfact <br />grout <br />ft. <br />O <br />•loran _ E <br />sacicn <br />gnyw Pack <br />ft. <br />MATERIALS/DEVELOPMENT <br />Casing type uW C_/ <br />Blank �i'J ft. Screen ft. <br />Slot size 0) U <br />Bags cement <br />Buckets bentonite / <br />Bags sand/gravel 0 0 <br />Filter Pack type/ 'zee <br />Surge Block: - ;/ ii ) <br />Discussed with geologist: - n ) <br />Type of method <br />