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WONLTLRWG W Ti,U INSTALLATION RSW <br />Date: a ?, f �/ I <br />Premise Address,?/ 3s IA)- /I�IrA <br />Well No.:I �n�O low <br />Inspector._/[�t'an <br />t— <br />Permit No. OC&5 :13 <br />Drilling Company: fi?�t <br />Driller: ��"" <br />Consultant�o F".. <br />Geologist <br />SPECIAL PERMIT INFO. <br />Distance to sewer line &JL <br />Domestic well on site - ( y / n ) <br />If yes, location and distance - <br />SAMPLING <br />Holding Temperature T oC <br />Method_ L/un.yL- Q <br />Screening Meth d <br />Tracking Shcet - / n ) <br />SPOILS <br />Storage Method <br />Contamination Noted - ( y /no <br />Storage Location <br />GROUTING <br />�/ <br />Depth to water D �S <br />Mix Ratios_ <br />Installation Method <br />Quantity Inst-If&-� L. <br />EH 29 29 <br />CONSTRUCTION <br />Total Depth / S <br />Screen Length (from) <br />(to) <br />Filter Pack (from) <br />(to) <br />Bentonite (from)—(to)— <br />from)(to)Grout <br />Grout(from) <br />(to) <br />Drilling rig type <br />Auger O.D. <br />I.D. <br />Completion - Stove pipe/cluistie box (circle one) <br />pravd Fade <br />Casing <br />Bags <br />Bags <br />san av <br />Filter Pack /size <br />Surge Block: / 11 ) <br />Discussed th geologist: - ( y / n ) <br />Type of m 1od <br />ft. <br />ft. <br />