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MONITORING WELL INSTALLATION REPOKT <br />Date:_1r� <br />Premise Address: <br />Well No. <br />Inspector: <br />Permit No. <br />Drilling Company: <br />Driller: <br />ConsultantlJt <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 />e_/ /' / <br />Holding Temperature, ' <br />Method rJe)A <br />Screening Method <br />Tracking Sheet - q7y/)/ n ) <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 <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 />casing <br />he; <br />ABovE-GPMND <br />coMPL.FrIon� crw,srr-aox <br />COMPL ETICN <br />Ground &xfacs <br />grout <br />ft. <br />. ft. <br />ft <br />= m <br />— C <br />_ O <br />1106d --- C <br />mien -� <br />grand pack <br />4. <br />ft. <br />MATERIALS/DEVELOPMENT <br />Casing type <br />Blank ft. Screen ft. <br />Slot size <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />Surge Block: - ( y / n ) <br />Discussed with geologist: - ( y / n ) <br />Type of method <br />