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PAGE <br /> _L_OF_ . <br /> Y ? <br /> -- d . <br /> G WELL INSTALLATION REPORT <br /> t a - <br /> 1. Dater CONSTRUCTION r <br /> Premise Addr ss: Well No. <br /> Inspector• Ssun i _ Total Depth <br /> Screen Length <br /> Filter Pack 2 2! <br /> Bentonite Pellets <br /> Permit No. Grout ' <br /> Consultant Completion-Stovepipe/christie box <br /> Geologist <br /> Auger O.D. T <br /> Auger I.D. <br /> SAMPLINGT- <br /> stick-up <br /> Holding Temperature -- <br /> Method T <br /> T <br /> screening Method ri <br /> ' ABOVE-GROUND CHRISTY-BOX <br /> r Tracking Sheet (y/n) COMPLETION COMPLETION <br /> Ground Surface - <br /> SPOILS <br /> 0 grout <br /> Storage Method <br /> Contamination Noted - yes no <br /> storage Location <br /> a <br /> SPECIAL PERMIT INFO. <br /> r!I slDtWd � <br /> Distance to sewer line section <br /> Domestic well on site - yes/no I;wck <br /> If yes, location & distance .- — <br /> GROUTING <br /> ti MATERIALS USED: <br /> Depth to water Casing ty e M <br /> Mix Ratios Blank_ .0 Screen- <br /> Installation Method Slot size <br /> Quantity Installed k Bags cement 1 hit <br /> 6 Buckets bentonite <br /> Bags sand/gravel <br /> Filter Pack type/size 7/ <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br /> f <br />