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1 <br /> w�..::,� -:;,r - _ ::;-.., - --�- _ - - ::;�-.,.• - - it <br /> M ORING WELL.INSTALLATION REPORT <br /> Date. Q2NSTRU93I0 <br /> Premise Address• Total Depth <br /> Screen Length (from) (to)��,-, <br /> Filter Pack (from) (ro) <br /> Well No.: l ..^� <br /> Bentonite (from) (to)_.__�_ <br /> Inspector. Sr81ti/ Groat (from) (to) <br /> I <br /> ng tYPe <br /> Permit No. Auger O.D. <br /> ( Completion-Stove p' chris a box circle one) <br /> Drilling Company: <br /> Driller: casinq <br /> height <br /> Consultant _EWT <br /> 4 <br /> Geologist ABOVS-GAOMO <br /> OQIr�LETION CHPJM41O% . <br /> COMP'LEnom <br /> SPECIAL PERMIT <br /> Distance to sewer line 4 1 <br /> Domestic Well on site - (y <br /> } If yes,location and distance- R, <br /> t glared t <br /> Holding Tem erature . = ¢svd Pads <br /> Method <br /> Screening Method QV M <br /> Tracking Shcet <br /> $Polls . <br /> Storage Method TERIALS EVEI.O <br /> Contaminadon Nosed - (y/n) PVC, <br /> Storage Location Blame type <br /> ° fy Screen €c. <br /> Slot size �— <br /> GROLrrTNG Bass cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel LA <br /> Mix Ratios Filter Pack typelsize <br /> Installation Method Surge Block: - (y/n} A- <br /> Quantity InstalledDiscussed with geologist - (y/n <br /> Type of method 4 <br /> EH 29 29 x <br />