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SV�90N' ITOlRlNG WELL INSTALLATION REP <br /> _ � , <br /> Date: ��`` l CONSTRUCTION - � <br /> Premise Address: v7 " �"� Total Depth ;. <br /> Screen Length (from) (to) <br /> Well No.: _ �'�/ Filter Pack , {from) (to) <br /> Bentonite (from) (to) <br /> Inspector: 1 �� Grout (from} (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant �a� '4 <br /> ,- <br /> Geologist_�zc-; ... f <br /> AEZ4AOUND CHR* Y-8OX <br /> COMPLETION COMPLETICN <br /> SPECIAL PERMIT INFO Ground surfaca <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) _. <br /> If yes, location and distance - - <br /> tt. <br /> ..c' <br /> SAMPLING a <br /> •lorai r� � <br /> tit aac1cn <br /> Holding Temperature f <br /> Method—V <br /> Screening Method 10 <br /> Tracking Sheet - / n ) <br /> '.Y <br /> fly <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - {y/ n) <br /> Storage Location Casing type ' <br /> �-- Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> . r - Buckets bentonite <br /> Depth to water 'f ` _ Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge BIock: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n) ` <br /> Type of method <br /> EH 29 29 <br /> } <br />