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R <br /> TORiNG WELL INSTALLATION REPO <br /> EL <br /> Date:_ � � CONSTRUCTION <br /> Premise Address: �i� Total Depth -7, 5 / <br /> Screen Length (from) la-7 (to)�_ <br /> Well No.: �/ ��' ! - (T i Filter Pack Cfrom) (to) c <br /> Bentonite (from) Cto) <br /> Inspector. Grout (from) � (to) <br /> � Drilling rig type `1-flii tv� 77 am 4, 1 <br /> Petmi[No. D d 73 S S Auger O.D. LD. <br /> Complerion - cove p' ' de box (circle one) <br /> Drilling Company: <br /> Drller. casing <br /> F height <br /> Consulran[ <br /> Geologist75/1 <br /> zT�� ABOVE-GAD <br /> Y•3CX <br /> CC)WLEE 1CN C <br /> CCMPt#APL_=TICN <br /> SPECIAL PERMIT INFO. nd S�"Y <br /> } ro <br /> grout <br /> Distance to sewer line 61111. <br /> Domestic well on site - ( y/ rift. <br /> If yes, location and distance - /.� ft. <br /> ;t. <br /> - = c <br /> = a <br /> SAMPLING alorai <br /> sacicn —_ <br /> Holding Temperature I v = G <br /> Method <br /> Screening Method — <br /> Tracking Shcet - ( y/ n ) <br /> SPOILS <br /> MATERIALS/DEVELOPME <br /> Storage MethodNT <br /> Contamination Noted - (y/ n ) 4 r�V <br /> Storage Location Casing type <br /> Blank i 2— fr. Screen IJ ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water 3 Bags sand/gravel ( h <br /> Mix Ratios Filter Pack type/siz J11 41 J <br /> Insralladon Method Surge Block: - ( e n) <br /> Quantity Installed a 5 Discussed with geo &gist: - ( y/ n) <br /> Type of method <br /> EH 29 29 <br />