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�P�� So►c� ��nl�, <br /> W�"Te"qG-WELL INSTALLATION REP* <br /> Date:q q-tl <br /> CONSTRUCTION <br /> Premise Address: 63414-ox.�/5,Lkv" <br /> Total Depth <br /> Well No,:- �'�- C jq Screen Length (from) (to) <br /> Filter Pack (from) <br /> Inspector: ,�. yop 4&ew Bentonite (to) <br /> (from) (to) <br /> Grout (from) (to) <br /> Permit No. S2 604 3 Drilling rig type _ <br /> Auger O.D. I.D. <br /> Completion - Stove i e clu-istie bo <br /> Drilling Company:_�A�E� ovs4�t7aivT5 P P / (circle one) <br /> X Driller: 7-/M D'4fcv <br /> casing <br /> Consultant 14t4j j-6R.(K) _ -T L;,►S E�vbtER�v� height <br /> Geologist_ <br /> ABOVE-GROUND <br /> SPECIAL PERMIT INFOCOMPLET;ON Gt-iF*7y-$GX <br /> . COMPLEMON <br /> Ground Suriaca „��, <br /> Distance to sewer line " <br /> Domestic well on site - (y/ n ) prcut <br /> If yes, location and distance - <br /> fto <br /> ft. ft. <br /> b <br /> SAMPLING _ <br /> Holding Temperature aecacn .8 <br /> Method <br /> Grlvw pads <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> 'F' e <br /> f to <br /> SPOILS <br /> Storage Method MATERIALS/DEVEI OPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location <br /> Casing type <br /> Blank ft. Screen <br /> GROUTING Slot size <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios Bags sand/gravel <br /> Installation Method Filter Pack type/size <br /> Quantity Installed Surge Block: - ( y/ 11 ) <br /> Discussed with geologist: - ( y/ n ) <br /> -;;1129 29 Type of method <br />