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MOTORING WELL INSTALLATION REPOK* <br /> Date: ZZ U 9 o y CONSTRUCTION <br /> Premise Address: 4 � � -weA / Total Depth s� <br /> T _ Screen Length (from) (to) 3 <br /> Well No.: p - 2-- Filter Pack (from) `7 1Z (to) <br /> Bentonite (from) 2-9 (to) 2-f- <br /> Inspector: _ Grout (from) (to) <br /> p Drilling rig type <br /> FT- <br /> I.D. <br /> Permit No. ►`-3q 3 q g Auger O.D. 12. _ <br /> C-_ Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: `�"^� <br /> Driller: 4;+e4)-f- t Z casing <br /> height <br /> Consultant 11rl-1 <br /> Geologist ABOVE-GROUND OON <br /> COMPLETIONGrou <br /> SPECIAL PERMIT INFO. nd Sudan + <br /> grout <br /> Distance to sewer line <br /> LsU <br /> Domestic well on site - ( y n uo ft• <br /> If yes, location and distance - 2g ft. <br /> = m <br /> _ m <br /> _= c <br /> -- o <br /> S.AMPL?NG alotted <br /> aac on <br /> Holding Temperature IXa"d Pack <br /> Method = <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method (A"4tAA- YLA? MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) &'I S.c It % 9V e <br /> Storage Location Casing type <br /> Blank .3o ft. Screen--Z S h• <br /> Slot size 02D" <br /> GROUTING Bags cement <br /> G� Buckets bentonite <br /> Depth to water ^ I O Bags sand/gravel — <br /> Mix Ratios `�ZV .� <br /> Filter Pack type/size 3 <br /> Installation Method Surge Block: - (y/ n) <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br /> x'22 '0 ��C 2 <br />