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&TORING WELL INSTALLATION REPO* <br /> Date: n� CONSTRUCTION <br /> U' <br /> Premise Address: /V� U('�t ALf �Vel— Total Depth <br /> Screen Length (from) I – (to) I <br /> Well No.: Filter Pack (from) (to) �7 <br /> Bentonite (from) –7 (to) I S' <br /> Inspector. �W Grout (from) (to) <br /> Drilling rig type #� <br /> Permit No. q i – Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: �( �� � l y �--e 64— <br /> casing f- I Y <br /> 171— fheightConsultant C��( OL�t` FI>Geologist �� �1( g)rY/U✓3 �t –� ABOVE-GACUND <br /> COMPLETION CHA15iY-aOX <br /> COMPLEnCN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> ft, <br /> If yes, location and distance - <br /> n. <br /> tt. <br /> _ <br /> = m <br /> SAMPLING donoi <br /> ►aC'cn <br /> Holding Temperature <br /> Method = <br /> Pack <br /> Screening Method <br /> Tracking Sheet - (y/ n ) _ <br /> n. <br /> SPOILS <br /> Storage MethodMATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y <br /> Storage Location 9l Y !I y ,m Casing type <br /> Blank_ ft. Screen U _ft. <br /> Slot size ( U <br /> GROUTING Bags cement 5 S Gl2( 1/✓ v <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios_ Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of metliod <br /> EH 29 29 <br />