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.ONITDRING WELL INSTALLATION REPS <br /> Date:Y 13O0? CONST O <br /> Premise Address:/ C�_ Total Depth <br /> '/ Screen Length (from) (to) <br /> y <br /> Well No.: AAA1 /, 21 �, IC-/ Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: V GV <br /> Driller: casing <br /> L/ height <br /> Consultant �' D� <br /> Geologist b" - � �� •� <br /> ABOVE-GROUND <br /> COMPLETION CNA35TY-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Sudws T <br /> Distance to sewer line <br /> prroart <br /> Domestic well on site - (y/ n ) ft <br /> If yes, location and distance - <br /> . ft. <br /> ft. <br /> D <br /> O <br /> C <br /> SAMPLING <br /> slot<ad c <br /> Bacton <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet (y/ n ) — <br /> ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) J/ �� <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios &_,. �nM- Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed r�-b Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />