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Date: <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 Temperature <br />Method <br />Screening Method <br />Tracking Sheet - ( y/ n ) <br />SPOILS <br />MONITORING WELL INSTALLATION REPORT <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 />Bags cement <br />Auger O.D. <br />I.D. <br />Completion - Stove pipe/christie box (circle one <br />ca.s 3- ng <br />height <br />ABO VE -G R CUND <br />cowFLETION <br />Cirntmd Surface <br />grout <br />• ft. ft. <br />- = m <br />— o <br />slo[tad <br />i-0G'Jof1 — <br />I= gravel Pack <br />ft. <br />ft. <br />Storage Method <br />Noted - ( y/ n ) <br />MATERIALS/DEVELOPMENT <br />Storage Location <br />Casing type <br />Blank ft. Screen ft. <br />GROUTING <br />Slot size <br />Bags cement <br />Depth to water <br />Buckets bentonite <br />Mix Ratios <br />Bags sand/gravel <br />Installation Method_ <br />Filter Pack type/size <br />Quantity Installed <br />_.__S.urge_Block:=_(.y_/ n_) <br />Discussed with geologist: - ( y/ n ) <br />EH 29 29 <br />Type of method <br />0 0 <br />