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APITORING WELL INSTALLATION REPOR'6 <br /> Date: / CONSTRUCTION �fa��✓�� ° ' <br /> Premise Address: / Total Depth <br /> Screen Length (from) (to) <br /> Well No.: �✓ Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) 2,5 (to) <br /> Drilling rig type d / <br /> Permit No. ��7 Auger O.D. I.D. <br /> / Completion - Stove pi sti box c e one) <br /> Drilling Company: G-a'� <br /> casing <br /> Driller: height <br /> t <br /> Consultant �k . 1 S T <br /> Geologist /5 /il�y1'f/ �r ABOVE-GROUND -T <br /> COMPLETION COMPLETION <br /> ' COMPLETION <br /> SPECIAL PERMIT INFO. Ground S + <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y tl n <br /> If yes, location and distance n <br /> ft. <br /> o <br /> _ e <br /> C <br /> _ O <br /> otWd <br /> SAMPLING sIa�ctlon — <br /> Holding Temperature <br /> Method <br /> Screening Method ' — <br /> Tracking Sheet - (y/ n ) - <br /> SPOILS <br /> Storage Method G)�L �� TC MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) <br /> Storage Location Casing type <br /> Blank Screen 2 u ' ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/.n ) <br /> Type of method <br />