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�,.*WORING WELL INSTALLATION REPONI� <br /> Date:_ a ( � I CONSTRUCTION <br /> Premise Address-��ss _ Total Depth oZs <br /> Screen Length (from) (to)_S r__ <br /> Well No.: _ rn 1& Filter Pack (from) ;IS (to) :5 8 ' <br /> Bentonite (from) -3 $" ( ) <br /> .�M to I � <br /> Inspector:----K-•-S4'4_� Grout (from) 'z (to) <br /> Drilling rig type l <br /> Permit No. Auger O.D. I.D. <br /> Completion-Stove pi a box (circle one) <br /> Drilling Company: _s� <br /> Driller:__ -d- casing <br /> height <br /> Consultant T <br /> Geologist <br /> ABOVEGROUND CNFitS1Y-80X <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO, Growd Surface <br /> Distance to sewer line ori <br /> Domestic well on site - ffX n) <br /> If yes, location and distance - , <br /> SANGWood <br /> ` = s <br /> Holding Temperatur _ sic-Jen <br /> Method = P <br /> Screening Method ► — <br /> Tracking Sheet / nD.) <br /> .? _i�. .._._.. ' tf. <br /> SPOILS <br /> Storage Method ' MATERIALS/DEVELOPMENT <br /> Contamination Noted - y it P <br /> Storage Location Casing type <br /> Blank ft. Screen aaac & <br /> Slot size e D <br /> G OUTING Bags cement <br /> r Buckets bentonite <br /> Depth to water.„ `t .*- Bags sand/gravel <br /> Mix Ratios Filter Packtyp;e/,;, r i <br /> Installation Method Surge Block: - n ) <br /> uantity Installed VDiscussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br />