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I TTORING WELL INSTALLATION REPOR', <br /> Date: f � CONSTRUCTION <br /> Premise Address: �� (� 'y� Total Depth <br /> Screen Length (from) __y___(to) <br /> 'C- <br /> Screen <br /> Well No.: o Filter Pack (from) (to)� <br /> r Bentonite (from) ' (to) <br /> Inspector: Grout (from) 6e (to)� <br /> Drilling rig type — 1 <br /> Permit No. Auger O.D. I.D. 41 7,41 <br /> - Stove pipe <br /> Consultant tie ox <br /> /_ � Completion (circle one) <br /> �y_� <br /> Geologist <br /> 37 <br /> SPECIAL PERMIT INFO. ABOVE-C'iROUND <br /> COMPLETION CHA M43OX <br /> Distance to sewer line PLETION <br /> Domestic well on site - ( y/ n ) Ground Surface <br /> If yes, location and distance - PER orou< <br /> z b ft. ft. <br /> SAMPLING <br /> e <br /> Holding Te p r tre 67 aloud <br /> Method S "ct°n <br /> Screening Method w: __ gravWpack <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method ���� MATERIALS/DEVELOPMENT <br /> Contamination Notes - y n ) �/G <br /> Storage Location G/1 S/�e� ` Casing type —� e iI� ��/ <br /> Blank Z.0 ft. Screen -2-n ft. <br /> Slot size n z, n <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> r Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/ n ) <br /> Installation Method Discussed with geologist: - ( y/ n ) <br /> Quantity Installed Type of method <br /> QAtd <br /> 1 <br />