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MO' iRING WELL INS7,ALI_A7ON R:.PORT <br /> Date: ��'Z Z CONST RUCTION <br /> Premise Address: 7ZO �- 6 Total Dep •s <br /> th Zd <br /> / Screen Length (from) 2 v (to) <br /> Well No.: (it/ / Filte: Pack (from) Zy (to) g <br /> Bentonite (frpm) $ (to) <br /> Inspector: _ Grout (from) (to) <br /> c; Drilling rig We <br /> Pe-:nit No. <Z Auger O.D. 1g` I.D. <br /> Completion - Stove pipe/chrstie box (circle one) <br /> Drilling Company: .Qc�`i <br /> cas_ng <br /> Driller. he; <br /> ♦ 7 <br /> Consul:anc C-' .,, j <br /> Geolo;ist �� = ABCVE-vACCNO CKq S_,Y•aCX <br /> Ground Sulacs . <br /> Sacrlar pERI�IIT INFO. i <br /> gr Out <br /> Distance to sewer line 50 <br /> Domestic well on site - ( y AD � <br /> If yes, location and distance - <br /> — e <br /> _= c <br /> — o <br /> sloR?d <br /> SAMPLING Lacon = <br /> -W pack <br /> Polding Temperature <br /> Me&.od — <br /> Screening Method <br /> Trac'.ting Sheet - (y/ n ) �- ♦ ' _ ♦ ft, <br /> SPOILS <br /> Scorage Method �7"" �"" ' MA17-PJAI-S/DEVELOPNENT <br /> Contamination Noted - ( y/ N <br /> Scorage Location Casing type <br /> Blank jO fZ Screen <br /> Slot size 0�- <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/ 10 <br /> Mix Rados i .�P.,r + 68 rQ Filter Pack type/size lC- <br /> Ins:allacion Me,.hod Surge 31ock: - n <br /> Quantity Installed /�-� Discussed with ge) ozst: - n ) <br /> Type of meshod <br /> l (6" PVC-) <br />