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\--JlO O NG WELL INSTALLATION REPG--.,' <br /> Date: <br /> CONSTRUCTION <br /> � <br /> Q T Total Depth <br /> Premise Address:, <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to)� <br /> Bentonite (from) (to) <br /> Inspector: _ +�� f _ Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove ipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant � �`' T <br /> T <br /> Geologist ASOVE-GF IOUND <br /> COINIa1 ETON COMPL 71CN <br /> C4MPt.ETION <br /> SPECIAL PERMIT INFO. Ground Surf=* <br /> Distance to sewer line >/ Grout <br /> Domestic well on site - (y <br /> If yes, location and distance - ft. <br /> ft. <br /> 4 <br /> SAMPLING riottad <br /> oG on <br /> Holdin Te erature _ <br /> g — gm%,W Pads <br /> Method VC. - <br /> Screening Method /U <br /> Tracking Sheet - y n ) _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type (J <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> i Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />