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1040NITDPJNG WELL INSTALLATION M*T <br /> Date: Z CONSTRUCTION <br /> 055 yj u I <br /> Premise Address: / `K Tota! Depth 13 <br /> Screen Length (from) 9�7 (to)_ cf p <br /> Well No.: fn) - Z Filter Pack (from) f �(to) 4 Z <br /> Bentonite (from) �h t (to) I u <br /> Inspector. Grout (from) sa (to)— jy <br /> Permit No. <br /> s� (� Drilling rig type <br /> Auger O.D. I.D. <br /> Completion - Stove pipe/chrisde box (circle one) <br /> Drilling Company: fiJ-�f f-�z 1/M.�A- <br /> Driller:__ hONn,—t casing <br /> height <br /> % <br /> Consultant_ S p 4 V <br /> Geologist ClL nnft��l�n� jt _ v <br /> ABCVE-GRC(JND <br /> COWLFriON CHR*'Y3oX <br /> SPECIAL PERMIT INFO CCMPLEncN <br /> C3ru:nd Sufan <br /> Distance to sewer liney+ <br /> Domestic well on site <br /> If yes, location and Qie ante - ft. <br /> 20 n. <br /> tt. <br /> SAMPLING = c <br /> aloCnd <br /> Holding Temperature - s'co`n <br /> Method_ �n JVT) DOS <br /> Screening Method <br /> Tracking Shcet Uy n ) _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - y n ) <br /> Storage Location /nn Casing type <br /> Blank —9'_ft. Screen 2O h. <br /> GROUTING Slot size <br /> Bags cement <br /> Depth to water 2 G t Buckets bentonite <br /> Bags sand/gravel <br /> Mix Ratios Filter Pack type/size z I I i <br /> Installation Method Surge Block: - (y n <br /> Quantity installed Discussed with geologist: - (y <br /> EH 29 29 Type of method <br /> EW . Z. <br />