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LM C. WELL INSTALLATION REPORT ' <br /> Date: 5' 3`73 CONSTRUCTION <br /> Premise Address: f(v0 S. '2T Total Depth (7 <br /> Screen Length (from) GO (to) <br /> Well NO.: / '¢ Filter Park (from) (to} <br /> Bentonite (from) (to)Insoector: Grout (from) 3(F (to) <br /> Drilling rig type <br /> Permit No.---F-5 ` �� Anger O.D. !D I.D. 77V <br /> Completion - Stove pipe/chrsrie box (circle one) <br /> Drilling Company: <br /> casing <br /> ,�,_ height <br /> Driller. <br /> r r � <br /> Consultant <br /> Geologist C�B�� -- — ABOVE-GROUND� COMRL.ri f0�! C.kiFitSY-3CX <br /> G=nd Sul=* <br /> SPECI?T PERMIT INFO. <br /> - grad <br /> Distance to sewer line <br /> Domestic well on site - (yA R g <br /> If yes, location and distance - 40 <br /> n <br /> slatiad �� <br /> SAMPLING sacsan x' - <br /> - — ;M ;tacit <br /> Holdiig Temperature <br /> Methodh' — <br /> Screening Method <br /> Tracking Sheet - y n } 620 ft. <br /> SPOILS <br /> Storage Method t MAi RIALS EVELOPMENT <br /> Contamination Noted - ( y/0 �Q�/'� <br /> Storage Location Casing type <br /> Blank x-'40 ft. Screen ZO ft. <br /> Slot size .67- <br /> GROUTING <br /> OZGROUTING Bags semen[ l <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> x Ratios 3 Filter Pack type/size <br /> Installation Method Surge Block. - V n) <br /> Quantity Installed 1 Discussed with geologist: - (y/ n ) <br /> Type of method <br /> 5: 3 -?-a <br />