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rvTORING WELL INSTAL LAI•ION REPOrit� <br /> a <br /> Date CONSTRUCTION <br /> � / <br /> Premise Address: ✓� �• Total Depth_ <br /> Screen Length (from)_ <br /> Well No.: �' 3 Filter Pack (from)_ 30 (to)— —� <br /> Bentonite (from) !O (to) LO 6 <br /> Grout (from).D 6 (to) O <br /> Inspector. �_ Drilling rig type <br /> Auger O.D. LD. <br /> Permit No._� Completion - Stove pipe/chnstie box (circle one) <br /> Drilling Company: /V a-el— O `� <br /> casing <br /> Driller: .. f — height <br /> Consultant - 0- A <br /> Geologist — ABOVE-GROUND Oy-p ygOX <br /> COMPLETION COMPLETION <br /> -- Grand Suri-act <br /> SPECIAL PERMIT INFO. <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - 0 n) �L I?ft. <br /> If yes, location and distance - /JD <br /> `� ft' <br /> ft. <br /> 0 <br /> O <br /> sianad _ <br /> SAMPLING section =_ <br /> Holding Temperature_,- a � — pa- <br /> Method <br /> aMethod <br /> Screening Method — <br /> Tracking Sheet - (y/ n)_ — a <br /> t 3D <br /> SPOILS <br /> Storage Method `_ MXi7FRIr: DT ELOPMENC <br /> Contamination Noted - y®n — Casing type 2", AT <br /> Storage Location h• <br /> Blank1l0 �ft• Screen— <br /> Slot <br /> Slot size .!:/Lo!o ___--.— <br /> Bags cement — P at 3' <br /> GROUTING Buckets bentonite— <br /> Bags sand/gravel -- <br /> Depth to waterer _ Filter Pack type/size•__ _1� <br /> Mix Ratios 7sr �r r'�� Surge Block: -1 y n) <br /> Installation Method Discussed with geologist: - (y� <br /> Quantity Installed - D Type of method <br /> EH 29 29' <br /> a� <br />