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_.. UNITORING WELL INSTALLATION REPO <br /> i <br /> Date: l I CONSTRUCTION f <br /> Premise Address: �S 5' Ul lJ\ Total Depth <br /> i (� � Screen Length (from) (to)f <br /> Well No.: � Filter Pack (from) -7� y (to) � <br /> Bentonite (from) -31 (to) -18 <br /> Inspector: -- f� a5� Grout (from) (to) t '-- � <br /> Drilling rig type ,JZT,3e n 74/`-() <br /> i Permit No. O O 3 b Auger O.D. g ` [ <br /> Completion - Stove pipe/ tie bo a one) <br /> ' Drilling Company: <br /> i <br /> Driller casing <br /> height <br /> Consultant <br /> Geologist_ Y L - — T <br /> ABOVE-GROUND <br /> CX 4itM43OX <br /> COMPLETION COMPLETION <br /> I SPECIAL PERMIT INFO. hound Strfan <br /> ilii Distance to sewer line �Om <br />' Domestic well on site • (y//7n <br /> 1 $ <br /> If yes, location and distant tL <br /> 1 <br /> SAMPLING &blt&d <br /> &*cion n — 3 ✓Zp <br /> Holding Temperature_ _ ,I <br /> Method C e r� _c _ 9rs Daae <br /> Screening Method (2D _ <br /> Tracking Sheet • y n ) s <br /> SPOILS <br /> i <br /> Storage Method _ _ Bf MATERIALS/DMLOPMENT <br /> Contamination Noted • ( / n ) <br /> Storage Location y _ Casing type Ty C— <br /> BI anlC �fL Screen E4 <br /> Slot size <br /> GROUTING f Bags cement <br /> Buckets bentonite <br /> Depth to water '- <br /> —_ _ Bags sand/gmvel <br /> Mix Ratios _ — Filter Pack type/size �r Z <br /> Installation Method Surge Block: - (yt{ r <br /> Quantity Installed — Discussed with geo gist: - (y/ a ) <br /> Type of method <br /> EH 29 29 LO0 - { � <br />