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MONITORING WELL INSTALLATION REPORT <br />Date:_ <br />Premise Address: <br />Well No.: <br />Inspector: khD k,u a <br />Permit No. b 6 & r. S� <br />Drilling Company: W p Q <br />Driller:_ DAto t,0( V06 <br />Consultant �r <br />Geologists <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 />CONSTRUCTION <br />Total Depth_ <br />Screen Length (from) Z (to) S'O <br />Filtet Pack (from)_ Z �t_(to) ��/1 <br />Bentonite(from)_ <br />Grout (from) (to)L_ <br />Drilling rig eC. <br />Auger O.D. I.D. <br />Completion -Stove pipe/C,591 e y (circle one) <br />casing <br />height <br />ABO VE -G A OUND <br />COMFL TION <br />Ground S urf aca <br />grout <br />C <br />elottad <br />s4caon <br />it. <br />Storage Method <br />Contamination Noted - (y / n) <br />MATERIALS/DEVELOPMENT - <br />Storage Location <br />Casing type_ .5,-L, �(o Py e 2 <br />Blank_ Z ft. Screen <br />GROUTING <br />Slot size 19, O Z Q <br />Bags cement 1 Z <br />Depth to water <br />Buckets bentonite Z <br />Mix Ratios <br />Bags sand/gravel <br />Installation Method <br />Filter Pack type/sir k <br />- - -- <br />Quantity Installed <br />------Surge_Block:—(-Y-/ _ <br />Discussed with geologist: - (y/ n ) <br />EH 29 29 <br />Type of method <br />