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� •r. <br /> E f <br /> TORING WELL INSTALLATION REPG+., <br /> .47 <br /> Date: $� CONSTRUCTION <br /> Premise Address: GtiJ' ' ��`�'" x Total Depth <br /> " ' Screen Length (from) (to); 5 -_ <br /> Well No.: la� ���` ��� ^- 4 Filter Pack (from) 2;6;� (to) `( ` <br /> ...-•Bentonite.- (from) (to) <br /> Inspector: 1d " ;: Grout (fro } (to)_ '- <br /> Drilling rig type '' 4 <br /> Permit No. " d � Auger O.D. . ' rl I.Dh2 ; <br /> a: Completion - Stove pipe/ch ristie box.,(circle one) - <br /> Drilling Company- <br /> Driller:' <br /> ompany: <br /> d <br /> Driller.• 6't�SS lI- ' casing <br /> height <br /> Consultant Rllk) <br /> Geologist � 5 n <br /> �. _...._ ., ABOVE-GROUND iCHMM-WX ` <br /> COMPLETION pN F <br /> SPECIAL PERMIT INFO. + ^*-- -. -. � •• ' d curd Suriac� <br /> Distance to sewer line <br /> Domestic well on site - (y n) 3 tt, <br /> If yes, location and distanc - • yw ,w i ft• <br /> 4. <br /> SAMPLING :Icro.� — G <br /> � •y ' " _ w soc�cn <br /> Holding Te perature = = grs pads u, <br /> Method ._173 '- � ZS f"� <br /> Screening Method l •' r ' <br /> Tracking Sheet y n ) ;, <br /> AZT <br /> _ H <br /> • ��w O <br /> SPOILS <br /> Storage Method D -CC4 R64A x MATERIALS/DEVELOPMENT R <br /> Contamination Not r�PIJCJ <br /> Storage Location Casing type <br /> Blank ft. Screen ZO ft. <br /> " Slot size ,Ola - I� <br /> GROUPING µ .E - Bags cement <br /> Buckets bentonites .A <br /> Depth to water �d� - *� � Bags sand/gravel WIZ <br /> Mix Ratios Filter Pack type/size 1-b <br /> Installation Method Surge Block: ' O/ n ) <br /> Quantity Installed Discussed with eulogist:.- dp/ n) „ <br /> Type of method <br /> EH 29 29 <br /> 'f <br /> IE " <br />