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TOPING WELL-INSTALLATION REPOn M <br /> Al. <br /> Date: <br /> � CONSTRUCTION <br /> Le <br /> �q <br /> Premise Address: Q � &. ' Total Depth <br /> p ` Screen Len (from) 2 (to -1•75 <br /> Well No.: �U !J Filter Pack (from) Z (to) 2-2— <br /> Bentonite <br /> -LBentonite (from) zZ (to) ?.y <br /> Ins ector ice-- Grout (from (to) d <br /> P Drilling rig type <br /> Permit No. 4 u Auger O.D. _ I.D. <br /> �� .. Completion -Stove pipe/christie box (circle one) i <br /> Drilling Company: Q9 <br /> Driller: 't- / casing <br /> height <br /> Consultan A4 llee � <br /> Geologisti�fGl'L� ,ttgpVl:-GFit�UND <br /> w COWLErfON CHPt_ET10RtS'TEno <br /> OM <br /> SPECIAL PERMIT INFO. Surlaca <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (yn <br /> If yes, location and distance ft' <br /> m , <br /> SAMPLING <br /> soc <br /> *-L <br /> tsongravelpads <br /> Holding Te per toreMethodScreening MethodTracking Sheet - y - t ` 2�: • tt. I <br /> SPOILS t�• - <br /> Stora <br /> gf� /� <br /> MATERIALS EVELOPMENT <br /> e Method <br /> Contamination Noted - n ��vzC <br /> u Casing type ft.Storage Location �s, .,� Blank• fr, Screen <br /> z. t . �. �• .02 <br /> Slot size <br /> Bags cement <br /> GROUTING Y �, �N '_ 'Buckets bentonite <br /> Y Z ` .. *� s avel <br /> n. Ba sand/gr <br /> . Bags <br /> Depth to water <br /> � � , � •� � Filter Pack type/size 3 <br /> Mix Ratios '(y <br /> '* Surge Block: - n -� <br /> Install atiori Method w ~Discussed with geologist:.- (y/.n <br /> ) <br /> Quantity Installed Type of method !* <br /> � •� G tom.r � a`�.• -+�, <br /> EH 29 29yw� <br /> r. <br />