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OMTORING WELL INSTALLATION REPO* <br /> a N � <br /> Date: /D J CONSTRUCTION <br /> Premise Address: 4�$ LO r � Total Depth <br /> Well No.: <br /> Screen Length (from)_ 2& (to) <br /> M -'114 Filter Pack (from) 2a (to) <br /> q Bentonite (from)�(to) <br /> Inspector. U i P.��'� l� P L ✓�rytp�(n ]kE <br /> Grout (from) <br /> Drilling rig type <br /> Permit No._ Auger O.D. I.D. <br /> Completion - Stove pip dtristie b circle one) <br /> Drilling Company IAI p"pS .� .7 tiytp �U yq o p, <br /> Driller:_ �/an l; '2 e- Ess- s -V yuk-c casing <br /> `� � height <br /> Consultant Pi i o ,oh.0�t tS r—h J i r J4,� v <br /> d d 25-5,m&7bkY <br /> Geologist l l) h/l�iin '[�i (bury n X-jazm� <br /> ABOVE•GRCUND <br /> COMPLETION CHALSIY 80X <br /> SPECIAL PERMIT INFO. COMPLETION <br /> Ground Surlsn <br /> Distance to sewer line__ IJn�(;n_oZ grout <br /> Domestic well on site - (y/ <br /> If yes, location and distance 4 3 ft. <br /> S tt. tt. <br /> SAMPLING <br /> Odorm c <br /> s°c9cn <br /> Holding Temperature_ <br /> Method inn c„-, n / ; = t nYd we <br /> Screening Method <br /> Tracking Sheet • (y/n) , <br /> SPOILS <br /> Storage Method $ - r1MS 0>7S,fc MATERIALS/DEVELOPMENT <br /> Contamination Noted • n <br /> Storage Location +0 Casing type elo <br /> Blank ft. Screen J.9 ft. <br /> GROUTING °�0inf°rl h yjjdrgtW Slot size In " <br /> > 3,o rn;17 l 1s. Bags cement Porf I a" I kax- r-1[ if elll"ax <br /> Buckets bentonite po-'e— '�6 "De th to water 2.P QO�� Bags sand/gravcl <br /> Mix RatiosL_ Z- /�$qJ(�.r Filter Pack type/size 2 o Cu f�C <br /> Installation Method F flz v Surge Block: - (y n <br /> Quantity Installed_ [ hafr L Discussed with geologist: - n) <br /> EH 29 29 Type of method LYY <br />