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$evtZTORING WELL INSTALLATION REPOR'%, <br /> Date: CONSTRUCTION <br /> 00 '�� ��/h`r o` Total Depth `N <br /> Premise Address- Screen Length (from) (to) <br /> Well No.: V tk� Filter Pack (from) (to) <br /> J Bentonite (from) (to) _ <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. ✓b Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company-.- <br /> casing <br /> ompany: casing <br /> Driller: height <br /> Consultant <br /> 7/41 T <br /> Geologist J, �L7 UGC' Aggyg-GACUND <br /> COMPLETION COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO.Surfact <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) -5 ft. <br /> If yes, location and distance 51 n, <br /> O <br /> SAMPLING •lorw� <br /> aodcn —_ <br /> Holding Temperature All"L <br /> Method <br /> Screening Method =_ <br /> Tracking Sheet (y�/ n ) <br /> SPOILS <br /> Storage Method /M, gz� , 7��� MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ <br /> Storage Location Casing tyRe ! <br /> Blank ft. Screen S ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water 7b Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method h Qib Surge Block: - (y/ n) <br /> Quantity Installe r Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br /> q� Aw I( <br />