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~ •� t ...JNITOWNG WELL INSTALL TION REPO. 4 <br /> �r <br /> C( , <br /> CONSTRUCTION A5 <br /> Date: <br /> Premise Address: L Tota! Depth <br /> Screen Length (from) b (to) S <br /> Well No.: Filter Pack (from)_ J �—(to) <br /> � . Bentonite (from) � —(to) <br /> , <br /> Inspector: Grout (from) <br /> Drilling rig type <br /> Permit No. Auger O.D. LD <br /> Completion - Stove pipe/ uistie box (circle one) <br /> Drilling Company-.- <br /> Driller: <br /> ompany:Driller: �� �1 �� casing <br /> height <br /> Consultant . t�� '4 <br /> Geologist <br /> ABOVE-GRCUND CHMM-BOX <br /> GO&FLEMN CompLEnoN <br /> PECIAL PERMIT INFO.Surfws <br /> D grout <br /> Distance to sewer line <br /> Domestic well on site - (y/n (Pt ft. <br /> If yes, location and distance <br /> Sa O <br /> wit <br /> SAMPLING slotted <br /> seeders <br /> Holding Tempera pack <br /> Temperature — <br /> Method Cie- u <br /> Screening Me od — <br /> Tracking Sheet <br /> SPOILS <br /> Storage Method grvA ..MATER.IALS/Dl VEI.OPMENT <br /> Contamination Noted - (y nC- Zt <br /> Storage Location � v► Casing type <br /> ,au.. ctbr.U�d <br /> BIank :: f <br /> t. Screen iS <br /> Dre11w� r � tin-$ kwSlot <br /> 5 DO?- <br /> 551M <br /> OZ <br /> SSya <br /> GROUTING nags cement <br /> ft. <br /> } Buckets bentonite <br /> Depth to water Bags sand/gravel a`15 <br /> Mix Ratios GVl Filter Pack type/ ' e 3 <br /> Installation Method �+ v. U� trout Surge Block:- <br /> y n ) <br /> Dicussed with geologist; n) N� C�Yt <br /> Quantity Installed - � � so - - <br /> _ g <br /> y r Type bf method g <br /> EH 29 29 ,a. -� ,. <br />