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*%ONr roRING WELL INSTALLATION REPOR'?" <br /> Date: CONSTRUCTION <br /> Premise Address: 3zot 6 m el! Total Depth O <br /> Screen Length (from) / (to) 3 o <br /> Well No.: e-kw /y Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. - o Grout (from) (to) <br /> Drilling rig type <br /> Permit No. �r 1� Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: /nom <br /> Driller: '✓!i /� 5�, ,., casing <br /> rl heLcht <br /> Consultant `j—h 70 -r/ C[m <br /> PTA <br /> Geologist <br /> ABCVE-GBCUNO C8RZ7Y-8OX <br /> CCNFLFFCN me <br /> SPECIAL PERMIT INFO. Ground Suiacs <br /> Distance to sewer line cut <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - ft, <br /> ft. <br /> • <br /> C <br /> o <br /> SAMPLING slor-ad <br /> sx'icn <br /> r ?s = <br /> Holding Temperature O'P-1 _ <br /> Method �v�Pack <br /> Screenin;Method = <br /> Tracking Sheet - (Q/ n ) <br /> SPOILS <br /> Storage Method l MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ no <br /> Storage Location Casing type bt rVc" <br /> Blank fr. Screen �• <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to Nvater till Bags sand/gravel /r' <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: -/(P/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />