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M(4W ORING WELL INSTALLATION REPORT <br /> Dale: CONSTRUCT ION <br /> Total Depth <br /> Premise Address: O Screen Length (from) © (to) <br /> Well No.: <br /> -- 7 Filter Pack (from) (to{to <br /> ) <br /> Bentonite (from) (to)� <br /> Inspector: �C/'�•f Grout (from) ) <br /> Drilling rig type cif 7 <br /> Permit NO.� �— _ Auger O.D. . /D/` I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Consultant <br /> � tticit-up <br /> Geologist <br /> SPECIAL PERMIT INFO. P TSO -GROUND CHRISTY-BOX <br /> o COMIPl.1~TfON COMPLETION <br /> Distance to sewer line ��gam{ <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - 9th <br /> - eft. <br /> �a p <br /> SAMPLING <br /> lwd` — o <br /> Holding Temperature e0tactan <br /> iI• <br /> Method .. _ <br /> Screening Method ImvW packr. <br /> Tracking Sheet - (y/ n) ' <br /> . M <br /> SPOILS <br /> Storage Method MATERIALS DEVELOPMENT <br /> Contamination Notes - ( y/ n ) 1/0 <br /> Storage Location Casing type <br /> Blank ft. Screen o`70 _ • <br /> Slot size . D <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> / Bags sand/gravel �- a <br /> Depth to water Filter Pack type/size <br /> Mix Ratios i� _ Surge Block: - J n ) <br /> Installation Method Discussed with geologist: - (�/ n ) <br /> Quantity Installed Type of method <br />