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N.,;NITORING WELL INSTALLATION REPOR <br />i <br />Date: <br />Premise Address: <br />Well No.: P"W -tf <br />Inspector: <br />Permit No. <br />Drilling Company: Lj <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 />Storage Method <br />Contamination Noted - ( y / n ) <br />Storage Location <br />GROUTING <br />i <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)- (to) <br />Filter Pack (from) (to) ` <br />Bentonite (from) (to) <br />Grout (from) (to) <br />Drilling rig type <br />Auger O.D. G ;77 I.D. . <br />Completion - Stove pipe/clu-istie box (circle one) <br />casing <br />height <br />7//,'d <br />ABOVE-GACUND <br />00MPL-E-7CN <br />V <br />Ground Surface <br />grout <br />rt. <br />ft. <br />oC <br />510roi —' C <br />sacicn <br />I— VAVV' Fade <br />1'(- ft. <br />MATERIALS/DEVELOPMENT <br />Casing type Me_- V <br />Blank SD ft. Screen <br />Slot size 0-v ' <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />Surge Block: - ( y / ti ) <br />Discussed with geologist: - ( y / n ) <br />Type of method <br />