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*ONITOFUNG WELL INSTALLATION REP : <br />Date: -/_L1—Premise Address: <br />Y <br />Well No.: - <br />inspector: <br />Permit No. <br />Drilling Company: — <br />Driller: <br />Consultant ©1 f <br />Geologist /-L � <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 />Depth to water_ <br />Mix Ratios <br />Installation Metho <br />Quantity Installed. <br />EH 29 29 <br />CONSTRUCTION <br />Total Depth <br />Screen Length (from) <br />Filter Pack (from) <br />(to) <br />Bentonite (from) <br />(to)__� <br />Grout (from) <br />Drilling rig type <br />I.D. <br />Auger O.D. <br />Completion - Stove pipe/cluistie box (circle one) <br />casing <br />A <br />:. :. <br />.. * . ComPLEEMCN <br />G=rd sumacs <br />grout <br />ft. <br />ft. <br />�__._.-fit• — <br />OC <br />aloro.� — <br />amcacn <br />-- gravel Pack <br />MATERI ALS/DEVEI.OP MENT <br />Casing type <br />Blank ft. Screen <br />Slot size <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />Surge Block: - ( y / Il ) <br />Discussed with geologist: ( y / n ) <br />Type of method <br />