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s- <br /> y MO INSTALLATION REI..,e r <br /> v <br /> � rr11 <br /> CONSTRUCTION �U I <br /> o <br /> Date: � 'WY <br /> Total Depth <br /> ?remise Address: Screen Length (from) (to) [�J <br /> 2. 5� Filter Pack (from) <br /> Well No.: I �. Bentonite (from) <br /> Grout (fro <br /> Inspector. Ding rig <br /> Auger O I.D. <br /> Permit No. Completion - Stove pipe/christi.e box (circle one) <br /> Drilling Company: U <br /> Tcasing <br /> Driller. T he_ghc <br /> Consultant • ' <br /> Geologist ,BCV`-GRCUNO c j- CS*-^'-8CX <br /> ArS'!=t 30N COMPti—,ICN <br /> Ground Su acs <br /> SPECIAL PERMIT INFO. <br /> grout <br /> Distance to sewer line �- <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - ft- -�-�--' <br /> 3 <br /> sbttad —' `a <br /> SAMPLING asccn <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - C y/ n ) _ <br /> SPOILS <br /> MATERLALS/DEVELOPMENT <br /> Storage Method // <br /> Conrarninarion Noted - (y/ n) Casing type <br /> Storage Location Blank fL Screen EL <br /> Slot size <br /> GROUTING ags cement <br /> uckets bentonite <br /> v ags sand/�avel <br /> Depth to water T ilter Pack size <br /> Mix Ratios a Surge Blo : - Cy/ n ) <br /> Installation Method D s d with geologist: - C y/ n) <br /> Quantity Installed — T of merh -- <br /> EH 29 29 � �� �� <br />