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h <br />` CONITOWNG WELL INSTALLATION up'—' <br /> Date: <br /> . 3 CONSTRUCTION <br /> - ! ., <br /> Premise Address: ���Z ��� Total Depth" --• <br /> � { Screen Length (from) fvZ (to) <br /> Filterac <br /> Pk (from) (to) 4' <br /> Well No.. I�w 5 i (to) <br /> Bentonite (from) 40 <br /> Inspector: Dn ru g rig (from) -4 <br /> _ 3 - -(o)��� <br /> e kcAoil <br /> Permit No. Atigeir.O.D. 'p I0 I.D. <br /> Completion.k Stove pipe/ u-istie bo (circle-one) <br /> Drilling Company: CWAVbA <br />'E Driller: :—fr.LL 14 <br /> height <br /> Consultant —or <br /> I <br /> Geologist <br /> ABOVE-GFtt.`UIVQ CHRiSTY-80X <br /> 009P ET16N COMPLETION <br /> SPECIAL PERMIT INFO. I Ground SWC <br /> Distance to sewer line ! <br /> grout <br /> Domestic well on site - (y n, it rte <br /> If yes, location and distanc - Z + ft• <br /> SAMPLING } slorai Y <br /> 3 <br /> Holding Temperature a4L UC socscn — �Pack <br /> Method <br /> Screening Method [jc> <br /> Tracking Street / n ) <br /> nL = <br /> -Y <br /> SPOILS <br /> Storage Method MA'TERIALgMEVEI.OPMENT <br /> Contamination Noted - / n ) y K <br /> Storage Location Casing type( i <br /> 5bofvx 04 JqVI L Blank eft. Screenw Z� _ft. <br /> Slot size <br /> GROUTING Bags cement I <br /> Buckets bentonite 2 -... <br /> Depth to hater U Bags sand/gravel <br /> Mix Ratios !2 ko Filter Pack type/ ize 3 <br /> " Installation Method 1 Surge Block: - y n } <br /> Quantity Installed Discussed with eologist: - y n } <br /> Type,!of method « (oG <br /> EH 29 29 } I. <br /> 3-qj3 <br /> � Ih <br />