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M CORING WELL INSTALLATION REPORT <br />Date:_7d— f <br />Premise Address: .? 3 �' <' 1/1 l <br />Well No.: <br />Inspector: <br />Permit No. <br />Consultant <br />Geologist <br />SPECIAL PERMIT INFO. <br />Distance to sewer line' �Z' <br />Domestic well on site - ( y /6 <br />If yes, location and distance - <br />SAMPLING <br />O <br />Holding Te rr� erature <br />Method /S -t ---, L <br />Screening Method <br />Tracking Sheet - ( y / n ) <br />SPOILS //99 <br />Storage Method 11 -ex � <br />Contamination N tes - (^ n) J dti <br />Storage Location ?Z, S (- - <br />GROUTING <br />Depth to water , Z <br />Mix Ratios (fV ' <br />Installation Method <br />Quantity Installed <br />CONSTRUCTION <br />Total Depth <br />Screen Length (from) <br />i '- (to) <br />Filter Pack (from) <br />(to) <br />Bentonite (from) <br />- (to) S <br />Grout (from? <br />> "% (to) <br />Drilling rig type i ` <br />1 / c0 <br />Auger O.D. �n' <br />I.D. <br />Completion - Stove pipe/christie box (circle one) <br />tt. <br />MATERIALS/DEVELOPMENT <br />"t <br />Casing type 4 "f'l)C" <br />Blank ft. <br />Screen 7 <br />Slot size !JJ o <br />Bags cement <br />1 -� <br />Buckets bentonite <br />Bags sand/gravel 2 / 7 <br />1 / c0 <br />Filter Pack type/size' <br />Surge Block: - ( y n�) <br />Discussed with geologist: - <br />( y / <br />Type of method <br />