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CTORING WELL INSTALLATION REPOIV <br /> Date: I ( _ 2� li CONSTRUCTION <br /> Premise Address: ��, c,� Total Depth <br /> Screen Length (from) (to) fa <br /> Well No.: I I 1 w I ���4� Filter Pack (from) ✓ (to) <br /> Bentonite (from) 0 (to) 2� <br /> Inspector. Grout (from) (to) c <br /> /� Drilling rig type <br /> Permit No. l I — /2 (IX �Y� n n Auger O.D. I. . <br /> Drilling Company: {"US -E'/t F t Pw Completion - Stove pipe/ stie box (circ! ne) <br /> Driller: Lo�r�b /''1G1;�1''l casing <br /> ��,,,, ��� � -�,,,, ,, /, _ � height <br /> Consultant—ia, o"�%�'� (, I`c't-� '4 <br /> Geologist lbL (?C G�[ L� _ T <br /> ABOVE-GROUND CHAISTY$OX <br /> t�MPLETK)N CCMPLEnCN <br /> SPECIAL PERMIT INFO. Ground Sutacs <br /> i <br /> Distance to sewer line grout <br /> Domestic well on site - (y/(n ft. <br /> If yes, location and distance <br /> R. <br /> SAMPLING Bored <br /> tedcn <br /> Holding Temperature <br /> gnviw Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) < _ <br /> SPOILS <br /> Storage Method — MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y <br /> Storage Location Casing type <br /> Blank 1 fr. Screen <br /> Slot size tot O <br /> GROUTING Bags cement <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 method <br /> EH 29 29 <br />