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W 7CRING WELL INSTAL:.aTiON R JORT <br /> Date: ! ' Z ( Z CONS-tUC ON <br /> P-emise Address: �D/� Tocal Depth <br /> Steen Lenge: (from) 7D (to) 6S <br /> Well No.: \ Filter Pack (E om) 3d (to) /0 <br /> J dentotdte (from) /3 (to) In <br /> Inspector. Grout (tom) (to) <br /> / �� Drilling rig type 53 <br /> Pe.=ic No. _ Auger O.D. I.D. _ 3 <br /> Completion • Stove pipe/ch stie box (circle one) <br /> Dr11Lng Comoany. _ <br /> f/ cas'_a5 <br /> Dr11er. r "`�t height <br /> Consultant G �� <br /> Geologist <br /> /30V:vAOIJND ( 1ccMp -�ZU <br /> Cl7tSY3CX <br /> C^.MP=C4 <br /> Gtwx)d S�rlaca . <br /> SPECIALPER-MITINFO. � <br /> � gnat <br /> Distance to sewer line <br /> Domestc well on site . ( y/ n <br /> If yes, location and distance - _ l3 I- <br /> — o <br /> slonod — c <br /> SAMPLING an — <br /> Holding temperature <br /> Method <br /> Screening Method <br /> T-acking Sheet - n ) <br /> 3b .c. • n. 1 _'. <br /> SPOILS —g '// <br /> Storage MUig <br /> ethod s MAi cRIAIS/DEVE-LOPNEN i <br /> Contamination Noted - y ) � <br /> Storage Location Casing We Z Y V <br /> Blank fr. Screen L5- fr. <br /> Sloc size -02—. <br /> GROLMNG Bags cemenr <br /> c� <br /> Buckets bentonite <br /> Dench to water Z 1 Bags sand/gravel <br /> MLc Rados Filter pack type/size <br /> Installation Method Surge Block: - (y n <br /> Quantity installed Discussed with geologist. - y n ) <br /> Tvpe of method <br />