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ATORING WELL INSTALLATION REPORT <br /> Date: I� I7 / 1 CONSTRUCTION O <br /> Premise Address: Total Depth <br /> ' /e r p � Screen Length (from) (to) <br /> Well No.: V �tXJ Filter Pack (from) (to) <br /> ,� Bentonite (from) (to) / Z <br /> Inspector: ' 1 ink-A., (�, Grout (from) (to) 0 <br /> "I 1 - ), S7 Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> �•) �p Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: I (.�ikl�� <br /> Driller: TV casing <br /> height <br /> Consultant �P tP� <br /> Geologist- e Q4,A, <br /> ABOVE-GACUND CNAISTY 80X <br /> CChiPIETION COMPLEnCN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line % oras <br /> Domestic well on site(zl y,/ n ) <br /> If yes, location and distance - It. <br /> a: <br /> — a <br /> = m <br /> — m <br /> = c <br /> SAMPLING dorod = c <br /> aec'cn <br /> Holding Temperature = qnVV' <br /> Pack <br /> Method EE <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) PVC <br /> Storage Location Casing type <br /> Blank_ Q h. Screen eft. <br /> Slot size Vol <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/ ' e <br /> Installation Method Surge Block: - n ) <br /> Quantity Installed Discussed wit eologist: - (y <br /> Type of method <br /> EH 29 29 <br />