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QONITOPJNG WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <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) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: <br /> casing <br /> height <br /> Consultant7 <br /> Geologist iABOVE-GROUND <br /> COWFLETON CNRSSTY c30X <br /> SPECIAL PERMIT INFO. Grour)d Suriaca COMPLEMCN <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n ) <br /> If yes, location and distance - ft. <br /> ft. <br /> I _ a <br /> fl <br /> 0 <br /> I fl <br /> SAMPLING = o <br /> s(ctiad — c <br /> aac"on <br /> Holding Temperature <br /> Method — g �+Pacs" <br /> Screening Method <br /> Tracking Sheet - (y/n) _ <br /> SPOILS <br /> Storage Method MATERIALS�EVELOPMENT <br /> Contamination Noted - (y/n ) <br /> Storage Location Casing type <br /> Blank ft. Screen 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 /> EH 29 29 <br />