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KOMITORINQ WELL INSTALTATION REPORT <br /> Dates AWgoQNSTRUCTION <br /> Premise Address s W Wp lgu. gg'6 1510414 . Well No. <br /> Inspector:----AeTotal Depth-- <br /> Screen <br /> epthScreen Length ON <br /> Filter Pack <br /> Bentonite Pellets <br /> Permit No. 16—ct(05 Grout <br /> ConsultantOki, Caepletion-Stove pipe/chrietis box <br /> Geologist <br /> Auger o.D. /—3S" •,I. Fors -5e�,�.14s► <br /> Auger I.D. <br /> Holding Temperature P <br /> Method_ , __ „• ^� <br /> Screening Method <br /> ABOVE-0HOUND CHPJY•)OX <br /> Tracking Sheet (y/n) GOWPL£TCH COMPLUM <br /> Qmwdswa * <br /> SPOILS t <br /> 9rwA <br /> Storage Method <br /> Contamination Noted - yes <br /> Storage Locatlon_ih -&lk 1.3 �• <br /> 19 <br /> b.• S <br /> SPECIAL PIMIT„*MA. — <br /> Distance to sewer line Kh”aCC <br /> PCD a <br /> Domestic well on site - yes/no <br /> If yes, location S distance <br /> G <br /> GRMIM4 <br /> M�ITERIALS ,g�EDs <br /> Depth to water1 g j say Casing type__ <br /> Mix Ratios #- t Blank �S__„_ ft. ScreenPZO ft. <br /> Installation Method Slot size_•, 0. 0ZIL •_ <br /> Quantity Installed Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> - Filter Pack type/size <br /> f' lar_9C-Slo tied <br /> ` 44.0 <br /> CC <br />