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I <br /> ORT <br /> KUT0PJNG WELL INSTALLADON r 4 <br /> 4 <br /> CONSTRUCTION <br /> i. <br /> Date: <br /> Total Depth (tO) <br /> Premise Address: Screen Length (from) <br /> Filter Pack (from) (to) <br /> Well No.: Bentonite' (from) (t°) <br /> Grout (from) (to) <br /> Inspector: Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion- Stove Pipe/christie box_ (circle one) <br /> Drilling Comp •any: <br /> casing <br /> height <br /> Driller.: —�• <br /> Consultant T <br /> l <br /> Geologist ABOVE-GROUND G}tRlsrt'-8aX t <br /> CO YF LETIO N COMPLETION <br /> Orour�Surixs <br /> SPECIAL PERMIT INFO. ora�t <br /> Distance to sewer line ft. <br /> ft. <br /> If yes, location and distance- ft• _ j IL <br /> SA1 - <br /> _ ¢ravel Pack <br /> Holding Temperature _ <br /> Method - <br /> Screening <br /> Tracking Sheet - (y/n) - ft. <br /> SPOILS ' <br /> mp TE,g1AL sz2EVELOPMENT <br /> Storage Method <br /> Contamination Noted - (y/n) Casing type <br /> Storage Location Blank_---.rt. Screen ft <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter packtype/size <br /> Mix Ratios _ Surge_Block:=(-y_/_n_) <br /> Installation Method Discussed with geologist: - (y <br /> Quantity Installed Type of method <br /> EH 29 29 <br />