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401v10NIT0RING WELL INSTALLATION REI (' <br /> Date: b <br /> CONSTRUCTION <br /> Premise Address,-- <br /> Total <br /> ddress: Total Depth Yc ' <br /> Well No,: Vbt fti - I f <br /> h "A t. I I Screen Length (from) moo` (to) r <br /> Filler Pack (from) <br /> Inspector. Bentonite (from)— litt5 (to)_ per_ <br /> Grout (from) (to) f— r= <br /> Permit No. z C)c1 � Drilling rig type <br /> Auger O.D.— <br /> Completion <br /> I.D. <br /> Drilling Company. Completion -Stove pipe/dn-istie box (circle cl�— <br /> rn <br /> Driller. (Q�,() n ' O <br /> ------ <br /> �_ casing <br /> Consultant. height <br /> v <br /> Geologist <br /> AECVEGACUND <br /> SPECIAL PERMIT INFO, COMFLETCN C4-GLm-3ox <br /> Ground Strfacs . COMPLEMN__ <br /> Distance to sewer line r <br /> Domestic well on s' - (y/n ) grout <br /> If yes, location d distance - <br /> ft. <br /> ft. <br /> SAMPLING _ <br /> doted — c <br /> Holding Temperature_(L� t socicn = .3 <br /> Method <br /> Screening method 1 (c7 <br /> Tracking <br /> Sheet -� n ) <br /> J •� <br /> SPOILS —4n-ft. It-- — R• <br /> Storage Method_ <br /> Contamination Noten r ( `"-- MATERIALS/DEVET OPMENT <br /> Storage Location„Q,,, / <br /> Blank type. Z �VC <br /> Screen a«_h <br /> GROUTING aC- fr- <br /> �G Slo[size ��� � <br /> Bags cement <br /> Depth to water N 1 Buckets bentonite <br /> Mix Ratios r o Bags sand/gravel <br /> Installation N <br /> Method n.�..�...� � Filter Pack type size_ <br /> QuantityInstalled_pL r, s Surge IIlock: - n ) <br /> Discussed with geologist: - (yAyj <br /> EH 29 29 Type of method <br />