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4, _jNITOWNG WELL INSTALLATION REPOT-- i <br /> Date: Z`I CONSTRUCTION <br /> Premise Address- D /�` Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. S 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: c49 inq <br /> height <br /> Consultant <br /> Geologist �7 <br /> /HOVE-GRICUND Cyd M43OX <br /> COMPLUION COMPLEnON <br /> SPECIAL PERMIT INFO. G=nd S <br /> Distance to sewer line gra <br /> Domestic well on site - (y/n ) - -;-ft. <br /> If yes, location and distance - M <br /> ft. <br /> �} MM <br /> 0 <br /> SAMPLING <br /> &*den <br /> Holding Temperature " - vol pacK <br /> Method — <br /> Zy <br /> Screening Method <br /> Tracking Sheet - (y/ n ) ;. .w . <br /> ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <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 BIock: - ( y/ n ) <br /> Quantity installed Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br />