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MO' RING WELL INS-.AL.I_kTION R PCRT <br /> Data: /l-/3�Z�������• CONS-7RUC ON <br /> pre^ise Address: {� 20 F. � �� , TOW Depth o <br /> Steen Le-ngth (Fora) (to) <br /> Well No.: / iff lFilter Pact (uom) (co) <br /> 0 (from) 33 (-,o) 3-I <br /> Inspector: f: r�-I3) Grout (from) 3 (to) <br /> Drilling rig type W /aod <br /> Permit No. • 2,0 , Auger O.D. 672-" <br /> - Stove pipe/ch sde box (circle one) <br /> Company <br /> casi:g <br /> Cr,r-'Iar: Aheigh` <br /> Ti ♦ i <br /> Consuicanc l C <br /> Geologist A� /l3C:VEvRC{:ND Clu+�fS TY-3Cx <br /> CcMP'=i�ICN <br /> Gr=lnd Su <br /> S?EC'A ?ER-M17 INFO. <br /> groc.•t <br /> Discance to sewer line X50 �� �. 2-9 <br /> Cor..esdc well on site - ( y n O' <br /> Ot <br /> If yes, lccation and distance - <br /> s <br /> [IOC.Qd r: — <br /> S p [scion <br /> -:clding Temperature � _ <br /> Method — <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) �► =% <br /> S?OILS <br /> Storage Method - —LO 1 VAERIALS/DEVELOPNEN-4 t <br /> Contaminadon Noted - (y n /r p �c <br /> Storage Location � 2,0f, Casing e �ti U <br /> Blank 35 _fr- Screen 1 C� :L- <br /> Sloc size . a 2 <br /> GROUIiNG Bags cement <br /> Buckets Lm_::o:'.� <br /> De,3dh to water Bags sand/gravel -dle= (- d= <br /> Mix RR.acos Seo / Y " � - r` 3b Filter Pack type/size / -33 <br /> Irscallac'on Metho Surge Block: - ( y/ n ) - <br /> Quant cy Installed Discussed wit,`t geologist: - ( y/ n ) <br /> T;ipe of anethod <br /> �l00 <br />