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•rORLNG WELL INSTALLATION REPCR.-- <br /> CONSTRUCTION ! <br /> Dace• �� � � C <br /> Premise Address: �� C Total Oeprh ` 's ; a 5- <br /> Screen Length (from) y _Cco) <br /> 3 CEO) �-z-�--- <br /> Well No.: W lit.) �- (n fit! � Filter pack (fro , <br /> Benmrsite (from) 3 CEO) <br /> Grout (gym) ` (to) <br /> inspector. OnUing rig type 129•P P-r'�� c v <br /> Auger O.D. tel, I.D. <br /> ?e=mir No. Compiedon - Stove pipet a (circle one) <br /> Drilling Company: U <br /> �nq <br /> Driller. <br /> Consultant__, c -- <br /> Geologist ,tgCvE-.aRCtMII CGM Y-oCX <br /> Cacaic�d SLsfr_a , <br /> SPECIAL PERMIT INFO. <br /> 4t� <br /> Distance to server line <br /> [77 ff <br /> Domestic well on site - ( y/ n) It' <br /> If yes, location and distance - <br /> Q <br /> SAMPLING <br /> c?olding Temperature <br /> Method ' <br /> Screening Method <br /> Tracking Shcet - C Y/ a) E�s = ♦ ��S <br /> ♦ 1L <br /> SPOILS <br /> Storage Method S <br /> MATERIALS/DEVELOPMSNT 7 <br /> Contamination Noced- . r"'^� a " PNf C' <br /> Casing type <br /> Storage Location '- � fa <br /> Blank _ iz Sceen_, <br /> Slot size a �' <br /> GROUTINGBags cement <br /> 31 r Buckets bentonite <br /> Depth to water <br /> -}� a ,S Bags sand/gravel <br /> Filter Pact[typesize <br /> V(ix R1IIOS <br /> stallation Yfet_`:od Surge Block: - ( y/ n <br /> In ) <br /> Quanciryailad Installed Discussed with geologist : - C Y/ n ) <br /> Type of rie_hod <br /> E:f 29 29 <br />