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Date: r 7 <br />h'7 <br />Premise Address: <br />Well No.: <br />Inspector: fes' <br />Permit No. <br />Drilling Company: VW. <br />Driller: <br />Consultant V - <br />Geologist <br />1 <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 />D� <br />Holding Te rr� erature <br />Method lSit <br />Screening Method <br />Tracking Sheet y / n ) <br />SPOILS �,,��`, <br />Storage Method 1500 '-�{ <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 />MONITORING WELL INSTALLATION REP,_ _. <br />CONSTRUCTION N <br />Total Depth <br />Screen Length (from) <br />Filter Pack (from). <br />Bentonite (from) <br />Grout (from) C� ! (to) <br />Drilling rig types • <br />Auger O.D. I.D. <br />Completion - Stove pipe/christie box (circle one) <br />MATERIALS/DEVELOPMENT <br />U <br />Casing e 2' PU'(-� <br />Blank ft. Screen ft. <br />Slot size C), d ZD <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />Surge Block: - (y 0 ) <br />Discussed with geologist: -CY) <br />/ n ) <br />Type of method <br />