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x 4&IT' ORING WELL INSTALLATION REPOnf - <br /> Date: c o _ CONSTRUCTION f <br /> Premise Address: l�O 2u" Total Depth V <br /> Screen Length (from) (to) <br /> Well No.: P Filter Pack (from) a (to) <br /> Bentonite'. (from)' . (to) <br /> Inspector: _ Grout v (from) (to) a <br /> Drilling rig type <br /> Permit No -��e 0O65;Y, Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> f Drilling Company:_/wr'�L Q <br /> Driller• casing <br /> . .. height \ . <br /> Consultant G' <br /> Geologist _ 7 <br /> A BOVE-GRQUND <br /> w COMPLETION COMPt EnON <br /> SPECIAL PERMIT INFO.:' G=nd Surface <br /> Distance to sewer line N 4grout <br /> Domestic well on site <br /> If yes, location and distanceO�. <br /> V 6� <br /> s SAMPLING - alood = <br /> h Holding Tempexature- N: _ " <br /> `Method* Lam .^ # ►Y : — gr'vse pads <br /> Screening'Method <br /> Trackin Sheet, y n•) _ r . _ 4' __ <br /> SPOILS <br /> Storage Method �S �'t+C MATERIALS/DEVELOPMENT <br /> Contamination Noted -, n-) OVA <br /> Storage Location` ' .° Casing type l _ <br /> Y . 4�. ' -`•,d f*` #Blank"""' �C] `" ft '�;`Screen'{� ft. <br /> �.� �`, ��,,"�` w; y1,�r, .Sri +i ay'�• `Y Slot size 820 <br /> GROUTING ' . 'k " Bags cementdc <br /> Buckets beiitoniteC�i <br /> -,-' Depth to water "� .-._.-' , '._ �. -.`:•- .. .:� Bags sand/gravel <br /> M <br /> i Mix Ratios r'` Filter Pack type/sizeF + <br /> Installation Method �"' `�= �'- "" #Surge Block:=".`(y °n <br /> Quantity Installed - Discussed with geologist: - (y/n) <br /> Type of method 4. <br />