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CTORING WELL INSTALLATION REPO* <br /> Date: CONSTRUCTION <br /> Premise Address: -42S La rel,. Total Depth 0 4'e,t <br /> rn W -23 W4s ;Ajto)4 Screen Length (from) _(to) �2 U <br /> Well No.: M W - 2-2 wii kay h m rev r Filter Pack (from) CQ0 <br /> f pw, Bentonite (from)�(to) <br /> Inspector. q"04 '1 PA 'hZe1M SAAse. 4S Grout (from) (to)- <br /> �- Mad_ 2z, Drilling rig type - S <br /> Permit No. _ al o b4 60 G Auger O.D. po I.D1q, .29-1 <br /> Completion - Stove pipe tristie bo (circle one) <br /> Drilling Company We e.ks c�Y � � � /tri 4nd��Vmf (f 0 , <br /> Drller: d m a' - rsa LI � casing <br /> rCuS C geSS- height <br /> Consultan 7oA5; GS v'1roxtmPtvl \ � <br /> 11 <br /> Y gssessm s <br /> Geologist JQ mp2 JaZ M 1'n ZIa LI <br /> w` n dn V I CO <br /> A80VE�3RCLIND Ci• mry-BOX <br /> Y3Yourn- D��i 3 MPLETION <br /> SPECIAL PERMIT INFO. S O G=rd Suix* <br /> �D®yv oraa <br /> Distance to sewer line AD 3, <br /> }C n o w Y\ 5 t <br /> Domestic well on site - (y' D 0, p�,p(� 3 • It <br /> If yes, location and distance - off ft•4Lj� <br /> Va' O <br /> q <br /> O <br /> SAMPLING doral = <br /> sarlcn = _ <br /> Holding Temperature Coo INw' t�� �� i C2 o(i = irravalpadt <br /> Method C'InI <br /> Screening Method I. y <br /> Tracking Sheet - (y/ n <br /> SPOILS 1 <br /> Storage Method 5 - A�e �Yi7m"Is-Q")ZJII c MATERIALS/DEVELOPMENT <br /> Contamination Noted • n) <br /> Storage Location 0-4 e Casing type Sc.h&-dule- 40 <br /> Blank S ft Screen /S ft. <br /> Slot size 0, 0 ) , <br /> GROUTING Bags cement <br /> ii- <br /> 1,,, Or !� Tinsulr'l! <br /> Ize+�bsF /4 . Buckets bentonite ut a 6o C rJ %n �/rh N <br /> Depth to water /4 , - Bags sand/gravel <br /> Mix Ratios tic1 q2 <br /> iL R1YICi Filter Pack type/size # <br /> Installation Method . % �Q Surge Block: - ( y/ no <br /> Quantity Installed Discussed with geologist: - rW n) <br /> ►11W22 Type of method hi AC <br /> EH 29 29 <br /> !0�i <br /> t�oTT•1 <br /> "�w3►� <br />