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b%,ATORING WELL INSTALLATION REPORv <br /> Date: �� CONSTRUCTION <br /> Premise Address: 46 11 Total Depth It <br /> Screen Length (from) (to) (a3 <br /> Well No.: Filter Pack (from) (v 3 (to) (00 <br /> ` Bentonite (from) (00 _ __(to) moi_f3 <br /> Inspector.. Grout (from) 13 (to) n <br /> Drilling rig type_ C-61 <br /> Permit No, 9 Z'.3 5 ap Auger O.D. Y.D. <br /> el A . Completion - Stove pip u tstiebo (circle one) <br /> Drilling Company- <br /> Driller: casing <br /> rrheight <br /> Consultant [ . , � _qWT <br /> GeoIogist_ ,,ii�[U�YL. <br /> ABOVE-GROUND CHRZ Y-BCX <br /> COMPLETION COMPLETICN <br /> SPECIAL PERMIT INFO. Orourd Scrface <br /> Distance to sewer line <br /> Domestic well on site - <br /> If yes, location and distance - ft- <br /> ft. <br /> Y' O <br /> SAMPLING <br /> Holding Temperature <br /> Method <br /> Screening Method Ak <br /> Tracking Sheet - (y/ n ) 7 _ <br /> ft- <br /> SPOILS <br /> Storage Method Lilo MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/( 3) �v,L <br /> Storage Location Casing type <br /> Blank tai ft. Screen / ft. <br /> Slot size .D Z_ ._ <br /> GROUTING Bags cement <br /> X21 l �/ Buckets bentonite <br /> Depth to water �� a5' Bags sand/gravel <br /> Mix Ratios I I Il x a, Filter Pack type/size <br /> Installation Method Surge Block: - (6y n ) <br /> Quantity Installed Discussed with geologist: - & n ) <br /> Type of method <br /> EH 29 29 <br />