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WTORING WELL INSTALLATION REPOn• <br /> Date: <br /> � CONSTRUCTION <br /> Premise Address: <br /> GSL 4 �• O� Total Depth <br /> TTr� Screen Length (from) Y _(to) <br /> Well No.: fl/G- Filter Pack (from, 6j� (to) <br /> Bentonite (from) Z-s-'S (to) 11.- S_ <br /> Grout (from) -2.c►- 5 (to) <br /> Inspector: Cir <br /> q Drilling rig type <br /> ;2 674 <br /> Permit No. Auger O.D. lam^ I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> 2. casing <br /> Driller: f <br /> 117 T <br /> height <br /> Consultant G <br /> Geologist P:!! /gpyE.GAWND <br /> Ci- <br /> COMPLETION COMPt.ETIONPLE noN <br /> Gcowurd <br /> SPECIAL PERMIT INFO. Surlacw <br /> < To grout <br /> Distance to sewer line <br /> Domestic well on site - (yn L(' 5 g, <br /> If yes, location and distance - <br /> _ a <br /> — o <br /> = m <br /> = c <br /> — o <br /> SAMPLING <br /> soc6on <br /> Holding Temperature X)O I - O_- _ = gr"l Pack <br /> Method = <br /> Screening Method <br /> Tracking Sheet - (y/ n) <br /> SPOILS = Ck. <br /> Storage Method 6' f LL.��r/� MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) Casing �0 n <br /> Storage LocationnPa <br /> z rj fr. <br /> Blank Screen ft. Screen <br /> Slot size n2v <br /> GROUTING Bags cement 111 <br /> Buckets bent nit! <br /> Depth to <br /> ti wate1rs Z Bags sand/gravel <br /> Pack <br /> type/ <br /> Mix Ratios } �} �'-� Filter Pack type/size <br /> Installation Method + Surge Block: - (y <br /> Quantity Installed Discussed with geologist: - (y <br /> Type of method <br /> EH 29 29 <br /> ti� �� �-Ll- D�{ IPE•/ <br />