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�NITO UNG WELL INSTALLATION REPO <br /> Data CONSTRUCTION _ <br /> Premise Address: <br /> �{ ' 'Dotal Depth � <br /> Screen Length MoMj< ;_(to)_... ., <br /> Well No.: Filter Pack (from) •T (to)--w <br /> Bentonite (from) (to) Z <br /> Inspector _ / Grout (from)_ &-M"-` (to) <br /> Dolling tig type rA&4jZ7 'T <br /> Permit.No. Auger O.D. O 'h" I I.D. `-ir' <br /> Completion-Stove pipe/christu box (circle one) <br /> Drilling Company: S <br /> Driller casinq <br /> l r�� height <br /> Consultant <br /> Geologist -- <br /> ABOVS-GACUNO Ct RWrf4WX- <br /> OOMPLVION COMPLJE M <br /> SPECIALLPMWT INFO, GrOUM$Wfow.. <br /> Distance to sewer line <br /> Domestic well on site- (Y . n, <br /> If yes, location and distance- R: <br /> �R. <br /> SaMNG _ slotted y = <br /> p secicn x: <br /> Holding Temperature <br /> �: -� •: GYM pSCI( <br /> Method ' "' <br /> Scr+eetung <br /> Tracking Sheet - n) —' <br /> s• = <br /> t CO <br /> .. - <br /> Storage Method__2 r, 94��t MATERIALS(DEVELOPMENT <br /> Contamination Noted- (y <br /> Storage Locadon__42aa._ Casing type uG Zck &2. Z <br /> Blank :,M- fr. Screen &-5 5 Z ft: <br /> Slot size h Z 0 <br /> G NG Bags cement r <br /> Buckets bentonite r <br /> Depth to water X77 Bags sand/gravel <br /> Mix Ratios " Filter Pack type/siu .r q/ <br /> Installation Method .c Surge Block: - (yFsris! <br /> QuantityInstalled Discussed with ge : /n) <br /> Type of method <br /> EH 29 29 <br />