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NITOWNG WELL INSTALLA'T'ION REPOI # <br /> Date: CONSTRUCTION <br /> Premise Address: T Total Depth ,t <br /> r Screen Length (from) _ (to) <br /> Well No.: <br /> Filter Pack (from) (to) <br /> �_ Bentonite (from) (to) <br /> Inspector: 'y' Grout (fro (to)– n <br /> 'Drilling rig type <br /> Auger O.D. �boxcir'cl Permit No. Completion - Stove pip stiee one) <br /> Drilling Company: zv� , <br /> J �„• r <br /> Driller: r casing <br /> } I IT <br /> tie_ght , <br /> Consultan <br /> 6Geologist ABOVE-GRAD <br /> CGMPLETi01� �? CiiFi;M-aoX <br /> COMptEno <br /> SPECIAL PERMIT INFO. Ground Sudwt <br /> ;i rout <br /> Distance to sewer line - y <br /> Domestic well on site - (y/n 416, : it• <br /> If yes, location and distance fL <br /> "—ft. <br /> 1 <br /> fir. q <br /> �C <br /> SAMPLING Vii' �Ivt:odi <br /> aoC en ' <br /> Holding Temperature ^ . _ 911 pack ,a <br /> MethodLOA 10 <br /> K — <br /> Screening Method r u- <br /> Tracking Sheet y n ) q <br /> 4 <br /> e <br /> SPOILS <br /> Storage Method 1��, _, MATERiALS/UEVELOPMENF <br /> Contamination Noted - (y <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size s <br /> GROUTING Bags cement 'f <br /> { t Buckets bentonite <br /> Depth to water . I Bags sand/gravel <br /> Mix Ratios } Filter Pack type/size <br /> Installation Method WG O 9 Surge Block: - (y n <br /> Quantity Installed - Discussed with geo ogist: ( / n ) <br /> �. <br /> r Type of method <br /> EH 29 29 � <br /> POV1 _ - <br />