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MO. ., iORING WELL INSTALLATION REPORT <br /> Date: ' U U ! I CONSTRUCTION <br /> Premise Address: P , p�� Total Depth (a 9 <br /> W W o Screen Length (from) (to) <br /> Well No. : � t! Q1b-Q �f W PSU Filter Pack (from) (to) <br /> f� Bentonite (from) (to) <br /> Inspector: ` 1 11 �11JY1 / Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I. <br /> �5 �LcKIdG� Completion Po Stove p ' a/chrisde box circle one) <br /> Drilling Company: [� <br /> Driller: �� � casing <br /> height <br /> COnSul[anC I �, � � � /y <br /> Geologist � °` <br /> ABOV&GRCUND CHR* Y-BOX <br /> COMPLEf10N COMPLEfICN <br /> SPECIAL PERMIT INFO. ground Sucfx+ <br /> Distance to sewer line I grout <br /> Domestic well on site • ( y / n ) <br /> If yes, location and distance - It. <br /> ft. _ ft. <br /> = c <br /> 4A W <br /> SAMPLING slotted _ <br /> ov <br /> son 3 <br /> nn -- oo I y ecti — <br /> HoldingTemperature ( A <br /> Method <br /> Screening Method OV M r = <br /> Tracking Sheet - ( y <br /> �ft. IL C===mmmmmpjfL <br /> SPOILS <br /> Storage Method dnwt:1 2 MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y / n ) 3 i <br /> Storage Location /M, RIND . Casing type PVC., /i) <br /> Blank A ft. Screen @7— ft. <br /> Slot size 4=;2 — <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y / n ) A <br /> Quantity Installed Discussed with geologist: - ( y / n ) <br /> Type of method ✓�/ A <br /> EH 29 29 <br /> I <br />