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it <br /> �WOINITOPJNG WELL INSTALLATION:REPO L <br /> Date: O CONSTRUCTION <br /> fj ' <br /> Premise Address: / W• C*V t"ud— Total Depth l <br /> Screen Length (from) (to) Z <br /> Well NO.: ' j C1 `2. Filter 3Pack (from) (to) <br /> Bentonite i (from) <br /> Inspector: Grout 1 (from)_ 17 ` (to)_ -a-- <br /> Drilling rig type 1 <br /> Permit No. r11 ' � � 'Z- Auger,O.D. '` &7 -I- <br /> t~Jts� Completion F Stove pipe/ stie (circle one) <br /> Drilling Company: <br /> i casing <br /> Driller• <br /> height + <br /> Consultant f t 621M j-24,20 'IT <br /> Geologist7//, <br /> CL►aZc Ill <br /> ABOVE-GROUND CHi1M BOX <br /> CO l�PLETi ON COMPLETICN <br /> SPECIAL PERMIT INFO. Ground Sudwe <br /> Distance to sewer line grout <br /> ro <br /> Domestic well on site - / n ) 7„ft- 1 <br /> If yes, Iocation and tance - <br /> Liztt. p <br /> SAMPLING <br /> adc�on <br /> Holding Temperature <br /> Pack <br /> Method ' <br /> Screening Method IWA3 <br /> Tracking Sheet CID( n ) <br /> SPOILS } I - <br /> Storage Method Old 9 GIDS MATE RIALSYDEVELOPMENT <br /> Contamination Noted - (2Y n <br /> Storage Location_ 6a 610ric _. Casing type �C— <br /> Blank: ft. Screen ZO ft. i <br /> Slot size I �•d�D <br /> GROUTING Bags cement CAKAJ <br /> Buckets bentonite (r <br /> Depth to water Bags sand/ 'gravel <br /> Mix Ratios Filter.'Pack type/size OQPr7ZsLC +Zvu <br /> Installation Method:76i4 L LUIS Illy L�Lbae ) Surge Block:, - / n ) <br /> Quantity Installed Discussed t geologist: <br /> Type merFiod <br /> EH 29 29 i <br /> t <br /> i IAF 4. 5' <br />