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41 <br /> 4MO1'I'ORING WELL INSTALLATION REPOR�d <br /> Date: 1 ` CONS"TRUCTION <br /> Premise Address: Total Depth <br /> 1 � <br /> Screen Length (from) (to <br /> Well No.: �A) Filter Pack (from) (to) •S <br /> Bentonite (from) (to) S <br /> Inspector dlt Grout (fro S` to) ac <br /> `� - 3c3S Ding rig type <br /> Permit No. Auger O.D. jfq V4 " <br /> Completion-Stove pi Christie bo a one) <br /> Drilling Company: LLQ <br /> Driller- „P-��o casing <br /> 1 T height <br /> Consultant W <br /> Geologist ... <br /> —qV <br /> ABOVE-GROUND CHRWY41OX <br /> OOhPLETION COMPLETION <br /> PERNT INFO, <br /> aroucd Suiaar.,..r. <br /> f <br /> Distance to sewer line < '50 <br /> Domestic well on site - ()((n q3,.5. <br /> If yes,location and distanc ,S iR <br /> _ <br /> a <br /> ---+�M -' <br /> Hold S Temperature P+dc <br /> Method <br /> Screening Method ,__._ <br /> Tracking Sheet - (y/ n ) ' <br /> .tLtt. % <br /> Emits <br /> Storage Method�s MATEgIALSLDEVELOPME 1�T/ <br /> Contamination Noted - (y n) ,. -7 <br /> Stomp Location �... Casing type 49 <br /> Blank 6 ft. Screen 2Zft. <br /> Slot size <br /> GROLITING Bags cement <br /> 61 bentonite �- <br /> Depth to water Bags sand/gravel d- <br /> Mix Ratios Filter Pack type/sizesD.��, .�.1z5t <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br />