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TOPING WELL INSTALLATION REPOR* <br /> Date: /�Z / CONSTRUCTION <br /> T7" <br /> Premise Address: Al CTotal Depth <br /> Screen Length (from) (to) :5(6 <br /> Well No.: Filter Pack (from) 5(- (to) <br /> Bentonite (from) (to) <br /> Insoector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No: 2' �3 Z Auger O.D. I.D. <br /> Completion :Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: � height <br /> Consultant s�fnnG� GO% -r <br /> Geologist C°G ABOVE-GROUND Ct A1SrY oCX T <br /> CONFL"TION <br /> . <br /> Ground$W IY.0 <br /> SPECIAL PERMIT INFO. <br /> r grout <br /> Distance to sewer lire �750 29. 7 tt <br /> Domestic well on site - (y 4�02/ 3•S n. <br /> If yes,.location and distance -, ft <br /> T. <br /> _ o <br /> O <br /> started d <br /> SAMPLING &*tion = B <br /> va <br /> Holding Temperature /✓O 4 etizdrN a = ��`� <br /> Method — <br /> Screening Method <br /> Tracking Sheet - n) <br /> SPOILS <br /> Storage Method D2L r1r,' MATERIA/DEVELOPMENT <br /> Contamination Noted - (y/ n) <br /> Storage Location Casing type !! <br /> Blank fr. Screen Z2 ft. <br /> Slor size <br /> GROUTING Bags cement <br /> (/ Buckets bentonite <br /> Depth to water TZ Bags sancdV/ e! <br /> Mix Ratios ".3 3aaelw cn+^•-T(JZ7ba � ) Filter Pack typesize 3 '� <br /> Installation Method .ww Surge Block: - (6 n) <br /> Quantity Installed = I Dams. Discussed with geologist: - (a n ) <br /> Type of method 6 <br /> O,roaCd� <br />