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WTORING WELL INSTALLATION REPOO <br /> Date: 3/2 CONSTRUCTION <br /> Premise Address: Total Depth h <br /> Screen Length (from) /1 I (to) 9/, <br /> Well No.: (!�G� ' ��� Filter Pack (from) //c4 (to) <br /> Bentonite <br /> Inspector. Grout (o)T �—(t) <br /> Drilling rig type <br /> Permit No. AugerO. I.D. <br /> Compleria - Stove pipe/cluisde box (circle one) <br /> Drilling Company:_ <br /> Driller: jABOVE-GROUND <br /> sing <br /> height <br /> Consultant i ��/�1C�1 ,Geologist ti,C ✓�/ TOMPLETION CiiAtSTY BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surfaet <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) '7 ' fL <br /> If yes, location and distance - c ' ft. <br /> Y' O <br /> M <br /> O <br /> SAMPLING = o <br /> slotted <br /> soclon <br /> Holding Temperature _ �G <br /> Method ; <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> 10 ft. tL <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing typeLsl.! <br /> Blank :4(-- ft. Screen ft. <br /> Slot sizer O Z. <br /> GROUTING Bags cement f 7 <br /> Buckets bentonite -b <br /> Depth to water Bags sand/gravel # f t o <br /> Mix Ratios Filter Pack type/stizeri <br /> Installation Me od Surge Block:rwl n ) <br /> Quantity Installed A (/ . ' %/ C?tw Discussed wit geologist. �y/ n ) <br /> EH 29 29 Type of method <br />