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NWRTORING WELL INSTALLATION REPOR' <br /> Date: o 1 CONSTRUCTION <br /> �� c17- <br /> Premise Address: � t-- Total Depth <br /> Screen Length (from) (to) (,1 <br /> Well No.: ll�-1 Filter Pack (from) (to) <br /> p Bentonite (from) 5 (to) <br /> Inspector. aL� Grout (from) 5? (to) <br /> Drilling rig type a-o /ta,�� <br /> Permit No. c1 �– — �l_3 Auger O.D. /o" I.D. <br /> Completion - Stove pipe/cl sue (circle one) <br /> Drilling Company: {2�" <br /> Driller: casing <br /> C height <br /> Consultant ll,) .,. <br /> Geologist <br /> ABCVE-GACCNO Cr+AsSTY-30X <br /> CCNVLFrZN C.^MPL�i 1CN <br /> SPECIAL PERMIT INFO. G=nd Suiaas <br /> � Qrcct <br /> Distance to sewer line <br /> Domestic well on site - y n) <br /> If yes, location and distance - S� ft. <br /> ft. <br /> SAMPLING 110r#d <br /> Holding Temperature <br /> Method <br /> Screenin; Method "< = I <br /> Tracking Sheet - Cy/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) OVA = <br /> Storage Location Casing type <br /> Blank ft. Screen � ft• <br /> Slot size <br /> GROUTING Bags cement <br /> 1 Buckets bentonite <br /> Depth to water `� Bags sand/gravel <br /> Mix Ratios I o0 N•►0 Filter Pack type,// ize <br /> Installation Meth p,rn, Surge Block: - W, n ) <br /> Quantiry Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />