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MORSNG WELL INSTALLATION REPORT <br /> ,s <br /> Date- _ n'!J'!` 1 C UC`nON_ S& d" Ovr KWAAA- <br /> Premise Address: I D Total Depth <br /> Screen Length (from) (to)�� <br /> Well No.: P- Filter Pack (from) (to),�_ <br /> Bentonite (from) (to)— <br /> Inspector. 4stti� . . Grout (from} (to) <br /> Drilling rig type <br /> Permit No. Anger O.D. I.D. <br /> Completion-Stove pipe/eluistie box (circle one) <br /> Drilling CompanY— AQjz1,1"�&4 <br /> Driller: casing <br /> hoigi:C <br /> �j Consultant <br /> Geologist <br /> Alra«LND <br /> coIo+wl companw <br /> SPECIAL + amurd sortae. <br /> Distance to sewer lice <br /> y Domestic well on sire- (y/a) R <br /> If yes, location and dismnce- ft. <br /> -- •• V <br /> SAMPLING n�om�// <br /> ik+jOA w <br /> i <br /> Holding Temperature <br />, Method j �P� <br /> Screening Method <br /> Tracking Sheet - (y/n) Y <br /> Storage Method 1VIATERIALS/I]EVELOPMt<I ' <br /> Contamination Noted - (y/n} �/s �C <br /> Storage Location Casing type y4 _ <br /> Blank (40 ft. Screen ft. <br /> Slot site Com" <br /> GROU_RNC Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel I <br /> Mix Ratios Filter Pack type/size ` <br /> Installation Method Surge Block: - (y/ n) N`k <br /> . Quantity Installed Discussed with geologisu�- <br /> Type of method- <br /> EH <br /> ethodEH 29 29 <br />