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WTORING WELL INSTALLATION REPOA <br /> Date: Z'0/0 3 CONSTRUCTION <br /> Premise Address: �S W' �/ z Total Depth <br /> Screen Length (from) (to) <br /> Well No.: 1'TSFilter Pack (from)�- 7 —(to)�*Z: <br /> Bentonite (from) (Q.4- 7 <br /> Inspector: Grout (from) (to) o <br /> Drilling rig type <br /> Permit No. 19 to 3 S7 l/ Auger O.D. $ I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: �` LO <br /> Driller: casing <br /> TffLT height <br /> Consultant <br /> l <br /> Geologist AjgO -GROUND <br /> COMPLETION CF6iIS"T`(-BOX <br /> PLE71C <br /> Grou <br /> SPECIAL PERMIT INFO. nd S 'o' <br /> 7 grout <br /> Distance to sewer line 1 �q <br /> Domestic well on site - (y/ n ) ft. <br /> If yes, location and distance - / 1i ft. <br /> JLC. <br /> m <br /> = c <br /> SAMPLING slotted = $` <br /> ax5on <br /> Holding Temperature = .+�P? <br /> Method = <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> �ft. — Lft. <br /> SPOILS <br /> Storage Method dam' /Niro MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y It J� <br /> Casing type <br /> Storage Location <br /> Blank 0 2_- ft. Screen 3c3u ft. <br /> Slot size G�o <br /> GROUTING Bags cement <br /> Buckets bentonitey — <br /> Depth to water ~^ Bags sand/gravel <br /> Mix Ratios Filter Pack type/size J' <br /> Surge Block: - (y <br /> Installation Method �3j <br /> 16a � "- �`3 Discussed with geo ogtst: - (y <br /> Quantity Installed / <br /> Type of method <br /> EH 29 29 <br />