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• ` RETpqRT <br /> MONCCORIAIGWFZZ.INSTALLAT[ON <br /> CONS CUON / <br /> Date: <br /> Total Depth <br /> Premise Address: ✓` �✓ Screen Length ChO1n) 9-3 —(to)�_ <br /> M Filter Pack (from — , <br /> Well No: /K Bentonite (from) - &_�--(t°) <br /> Grout (from)_�—(CO) <br /> Inspector. Drilling rig type "B gI.D. <br /> rJ �p�pC7`j3 Auger O.D. /_ // <br /> permit No. Completion - Stove pipe/cltrutie box (circle one) <br /> Drilling Company <br /> : casing <br /> � <br /> Ku(C✓�Z height <br /> Driller: 70, IFM <br /> Consultant <br /> I e- C of ABOVE-GfICUND C'�nZT'Y-O <br /> Geologist pO W LET{ON Cp�,.t?L=i1cN <br /> SPECIAL PERMIT INFO. graE <br /> Distance to sewer line It' <br /> Domestic well on site = (Y <br /> if yes, location and distance - n, <br /> I = <br /> ilon�i =_ c <br /> SAMPLING socicn <br /> _ tnvdPack <br /> Holding Temperature <br /> Method — <br /> Screening Method <br /> Tracking Sheet - (Y/ n) <br /> �n. <br /> SPOILS <br /> MATERIALS/DIDIELOPMENT <br /> Storage Method <br /> Contamination Noted - (Y/ n) Casing type gcreen_� <br /> Stora Location Blank <br /> Slot size <br /> Bags cement <br /> GRO G Buckets bentonite <br /> Bags sand/gravcl <br /> water <br /> Fater Pack type/size <br /> Depth to <br /> Mix Rados Surge Block: - (geologist: - (Y/ n) <br /> ipstalladonMethod Discussedvrith <br /> Quantity Installed Type of method <br /> EH 29 29- <br />