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rvI�..TORING WELL NSTALLATION REPOmi <br /> CONS�N <br /> Date: ' <br /> Total Depthv (to) <br /> Premise Addr ss: Screen Length (from) <br /> Filter Pack (from) O (to) <br /> WellNo.: /'uf/ Bentonite (from) (to) <br /> Grout (from) (to) <br /> Inspector: Drilling rig type G^^ v s <br /> f �D3�16 3 Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/chnstie box (circle one) <br /> Drilling Company: <br /> 4�Q� <br /> �� casing <br /> Driller: height <br /> iy <br /> Consultant <br /> Geologist AE&F-GROUND C4-SZ7y-8OX <br /> COMPLETION COMPLE71ON <br /> Ground Sacs <br /> SPECIAL PERMIT INFO. �f L �� grout <br /> • 6 ^m <br /> Distance to sewer line �� � 5V �7C/ ft. <br /> Domestic well on site - (y n ft. <br /> If yes, location and distance - f �Lo ft <br /> ,c, <br /> SAMPLING n 4 �j V;y wc6on I <br /> m e ature <br /> Holding Te o p <br /> Method r <br /> Screening Method <br /> Tracking Sheet - n ) tt tt. <br /> SPOILS <br /> SS � MATERIALS/DEVELOPMENT <br /> Storage Method J Z,� I– <br /> Contamination Note - ( �� x � 6 Casing type_ ft. <br /> Storage Location Blank $O_�fr. Screen AA <br /> i <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> p r Bags sand/gravel 8 <br /> Depth to water' ( I� o Filter Pack type/size 3 <br /> Mix Ratios Surge Block: - (Y n <br /> CID <br /> Installation Method Discussed with geo ogist: - (y <br /> Quantity Installed //�Com— Type of method <br /> EH 29 29 <br />