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PAGE_.&OF__3 <br /> ia� G WELL INSTALLATION REPORT <br /> Date: ��'9 - CONSTRUCTION <br /> Premise Address: . iX {)Q Well No. �3 f <br /> Inspector: Total Depth 400ALI '104r (39, <br /> SM-f Screen Lenh <br /> Filter Pac Z L 2 a <br /> Bentonite Pe let <br /> Permit No. (oQ Grout <br /> Consultant Completion-Stovepipe/ hristie box <br /> Geologist � <br /> Auger O.D. 11 <br /> A. <br /> Auger I.A. <br /> SAMPLING -- ---- --- -- <br /> Holding Temperature stick-up <br /> Method <br /> i Screening Method <br /> j ABOVE-GROUND CHRISTY-BOX <br /> Tracking Sheet {y/n} COMPLETION COMPLETION <br /> Citaund Sumacs <br /> I SPOILS <br /> - grout <br /> Storage Method vLk (-- <br /> Contamination Noted - e no n' <br /> Storage Location <br /> �- ..eft• <br /> � _ m <br /> rr A <br /> SPECIAL PERMIT INFO. �I <br /> 8106d <br /> Distance to sewer line baa <br /> I Domestic well on site - yes/nopack <br /> _ <br /> If yes, location & distance - <br /> GROUTING <br /> MATERIALS USED: <br /> rt <br /> Depth to water Casin t p V <br /> Mix Ratios Blank ft. Screen ft. <br /> Installation Method Slot siz <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Hags sand/gravel <br /> Filter Pack type/size r2 <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br /> { <br />