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MINORING WELL INSTALLATION REPORT <br /> Date: 2. R _ CONSTRUCTION - <br /> Premise Address& Total Depth- ' <br /> Screen Length (from) (to) <br /> Well Na.: Filter Pack (from) _ <br /> Bentonite (from)v�_ ^_(to y <br /> Inspector: -_ M _ Grout (from <br /> (to <br /> Drilling rig type <br /> Permit No. Auger O.D. 'Intl h <br /> r Completion - Stove pipe; sne bo a one) <br /> Consultant <br /> -&)2� <br /> Geologist , r stk*-up <br /> SPECIAL PERMIT INFO. •" <br /> ABOVE-GROUND � <br /> COWLETION. CHRIS7Y-BQX <br /> Distance to sewer Iine µ H COMPLETION <br /> Domestic well on site - (y/ Grourd$Lwf°O° <br /> If yes, location and distance - ;grout <br /> ca Ic <br /> SAMPLING <br /> Holding Temper e slotted :i = <br /> Method i sacson <br /> Screening Me o graxvl pack <br /> Tracking Sheet n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT - r <br /> Contamination Note y n } 4I&nt x •!J j�,. <br /> Storage Location Zi Casing We � <br /> Blank ft. Pireen ..0 ft. <br /> ' Slot size .bZa <br /> ro r .Bags cement <br /> GROUTING Buckets bentonite v n Q1 <br /> r . 4 <br /> E Bags sand/gravel <br /> Depth to water_ Filter Pack type/siz ► <br /> Mix Ratios �_ Surge Block: - (y n <br /> Installation Method Discussed with geologis n ) <br /> Quantity Installed Type of method <br />