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In4NM<ITOi RING WELL,INSTALLATION REPO1%f <br /> Date: lVCY7J <br /> CONSTRUCTION C, r <br /> Premise Address: 2. Total Depth 7 , <br /> 2295:6 `-fir Screen Length (from) (to) <br /> 7 Well No.: ` Filter Pack (from) (to) <br /> C d ..... Bentonite (from) (to) <br /> Inspector: x- nA Grout (from) (to) O <br /> {� ( s Drilling rig type <br /> pp /0 2 Au ger O.D. <br /> ComI.D. <br /> Permit No. D'r % y <br /> - �, pleuon -Stove pipe/chrisne box ( irde one) <br /> ' Drilling Com�panIAbe <br /> ly: � _ - <br /> �hf��� � n .... - ^• casing - .. <br /> Duller: height " <br /> r ir •�" G <br /> Consultant.__ � � <br /> Geologist <br /> gi 8t• n ABOVE-GROUND <br /> `si � CiiAfSiY430X <br /> Nt�;.•, ., ^, s� "�"R ,;, ��,zc,� :CCMPLETION CCMPI-ETIO <br /> •(�.',,. . - - "• Surface <br /> SPECIAL PERMIT INFO <br /> ,���Grourd <br /> ,.rCJ�r '�D •4 f. .�'"„ ""k -#4• , 4 .� , <br /> grout <br /> '• - Distance to sewer line..,, •" � � <br /> Domestic well on site - (y 4'n)t +b ?« d •: 4 3 ft• <br /> If yes, location"and distance - _ ! t a ft. <br /> SAMPLING aLa=-_ ` t _ ,� ,:silt <br /> Holding Tempejature yT"rel pads <br /> L4 E' l.T 1 <br /> Method •:• �,�:--` ,.-c,^ <br /> Screening Method <br /> Tracking Sheet- - n) <br /> ` � �'_. •. �'� --sem.:, ,.,. \:.+"�:;•'' � `���'F.$y .. . <br /> I SPOILS <br /> Storage Method � <br /> MATERIALS/DEVELOPMENTti t <br /> Contamination Noted - (y'l J "e ° 3�-g Z' <br /> Storage Location ���� ;j �' — Casing type <br /> r Blank ft. Screen Za fr• <br /> Slot size OTA' <br /> .. s;A4r.� Bags cement <br /> GROUTING Buckets bentonite <br /> Depth to water <br /> 42:. S6 ` b Bags sand/gravel <br /> Mix Ratios Fflter Pack type/size 3 <br /> Installation Method a V' k eo&rr Surge Block: - n) <br /> Quantity Installed --'t Alto/ Discussed with geologist: - n) <br /> Td ype of method WOW <br /> vh" a "�+.. ,, :' 1 i - �" 'S' w��;:.`•end S.->, i• ;;,, V» -. '.\.ri�.. <br /> EH 29 29 <br /> i <br /> i r- <br />