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�ORING WELL INSTALLATION REPOR9 <br /> Date CONSTRUCTION CONSTRUCTION �( t <br /> Premise Address: Total Depth `b <br /> r Screen Length (from) 37.S (to) O t <br /> Well No.: �� Filter Pack (from) S 1 (to) O' <br /> Bentonite (from) 3 3' (to) <br /> Inspector. Grout (from) (to) 33 <br /> Drilling rig type�t,,,,� <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling Company <br /> l - � casing <br /> Driller: �)�� � he±ght <br /> Consultant, 'i°'Coke <br /> Geologist rneJ>�� PeA �-L ABOVE-GROUND erasry-Box <br /> SPECIAL PERMIT FO.SutxY <br /> IN +_e <br /> grout <br /> Distance to sewer line 3 3 <br /> Domestic well on site <br /> If yes, location and di- ncAPE e - h• <br /> n• — <br /> v}} O <br /> _ M <br /> i•� O <br /> SAMPLING slorai <br /> socicn = <br /> Holding Temperature <br /> Method <br /> Screening Me <br /> Tracking <br /> = <br /> Tracking Sh (y/ n) <br /> SPOILS <br /> Storage Method SS N V" MATERIALS/DEVFI.OPMENT <br /> Contamination Noted - ( n CasingPO a�wtt c S <br /> Storage Location s� ` ➢ a K <br /> V � BlankS.�C34sfr. Screen 2, � <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel�^� <br /> Depth to water J 3 D Filter Pack type/size # 3 A <br /> Mix Rados Surge Block: - (y/ 11) <br /> ipstallation Method Discussed vAth geologist: - (y/ n ) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />