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''!C6wroPING.WELL INSTALLATION REP(A <br /> Date: ��-� 0 S CmdT ucncy <br /> Premise Address: 0 �b } t Total Depth g6 • l b <br /> Screen Length (from) (to) <br /> Well No.: a Filter Pack (from) (to) <br /> / 0 Bentonite (from) (CO) <br /> Inspector. Grout (from)_ (to) <br /> Drilling rig type <br /> Permit No. Auger O.U. � cD I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: JA�� casing <br /> _ —:F heirht <br /> Consultant <br /> Geologist % -- <br /> ABOVE-G R CUND C.HR ZTY-BOX <br /> SPECIAL PERMIT INFO. Strfact <br /> Distance to sewer line grcut <br /> Domestic well on site - (y/ n) „ - -It• <br /> If yes, location and distance - <br /> It. <br /> .Y. C <br /> M <br /> v <br /> SAMPLING ilarci <br /> sac�cn � <br /> Holding Temperature <br /> Method _ r <br /> Screening Method }` <br /> Tracking Sheet (y/ n ) _ <br /> ft. = tt. <br /> SPOILS �]' 90,76 <br /> Storage Method M .� SS MATERIALS/D (bv' <br /> Contamination Noted - (y <br /> Storage Location Casing type � <br /> Blank. b- - - - ft. Screen La ;t- <br /> Slot size 0 -02-0 <br /> GROUTING nags cement �— <br /> C, Buckets bentonite <br /> Depth to water �D -7 � 6 Bags sand/gravel <br /> Mix Ratios_41&A&- _ Filter Pack type/size <br /> ipstalIadon Method #. Surge Block: - (y/Il} <br /> Quantity installed alAD a- `� •� Discussed vrith geologist: - 6/ n) <br /> Type of method •�✓ <br /> EH 29 29. . <br />