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M(jfORING WELL INSTALLATION REPORT • <br /> Date: �2-?3 CONSTRUCTION <br /> Premise Address: �/ / ��" "` Total Depth Z5 <br /> Steen Length (from) Z (to) S <br /> Well No.: G�S / Filter Pack (from) 2-5 (to) _ <br /> Bentonite (from)�Cto) Z <br /> Inspector: <br /> w Grout (from) 2 (to) <br /> p <br /> _ Drilling rig type 2 <br /> Permit No. li" Jr Auger O.D. <br /> Completion - Stove pipe/ stie box (circle one) <br /> Drilling Company: J� <br /> casing <br /> Driller. ��'� �� height <br /> Consultant 4 <br /> g <br /> ELtIGGwtCHRZ-Y-BOX\ <br /> Grologist � `;'RC 'ND <br /> CohV -,ICN C^.MPI=iICN <br /> ���around S�rtx+ <br /> S?cCIaL PERMIT INFO. <br /> procrt <br /> Distance to sewer line <J�a —�_R. <br /> Domestic well on site - ( y/Q tt. <br /> If yes, location and distance - _,�L_ft. — <br /> — 3 <br /> — e <br /> = n <br /> — C <br /> — O <br /> 21oIUd — 0 <br /> tac9on = a <br /> SAM?LING — <br /> Holding Temperature 6M Bei <br /> Method l , <br /> Screening Mer-hod <br /> Tracking Sheer - n ) 25 tt, 7 <br /> SPOILS <br /> Storage Method ME`i'R�jn�LOPME <br /> NT <br /> Contamination Noted - n Casing type <br /> Storage Location 011 DIi Blanc fc Screen ft- <br /> Slot size / <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Dep ~T� Bags sand/ <br /> th [o water ave <br /> Dep Rados Filter Pack a/size <br /> las:allat:on Method Surge Block- - C y/ n <br /> Quantiry Installed Discussed with geo�st. - (y/ n ) <br /> Type of method <br />