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`,.�TORING WELL INSTALLATION REPGr.,,� <br /> Date: ' �( 'q CONSTRUCTION <br /> Premise Address: (C61 S, t-t Total Depth / 7 <br /> Screen Length (from) /(,--, (to) 7 <br /> Well No.: M l,-) ( Filter Pack (from) 17 (to) <br /> Bentonite (from) & (to) -S' <br /> Inspector: C Grout (from) 5 (to) a <br /> Drilling rig type <br /> Permit No.—q 1 7 c) Auger O.D. S.2 � 2 <br /> Completion - Stove pip cl s e box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant Cbl W7:F <br /> n <br /> Geologist 19404-) -E <br /> ABOVE-GRCUND CHR*7 _8Ox <br /> CONFLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line y5D grout <br /> Domestic well on site - (yn ft. <br /> If yes, location and distance - ft. <br /> ft. <br /> v• o <br /> SAMPLING •brei = <br /> �o sec�cn <br /> Holding Temperature _ „iw <br /> ack <br /> Method 1 <br /> Screening Method <br /> Tracking Sheet - n ) <br /> tt. — M <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ,, <br /> Storage Location e>LA GIng- Casing type -2 se6d 40 �- <br /> Blank 7F ft. Screen ft. <br /> Slot size 0,2_0 <br /> GROUTING Bags cement <br /> ! Buckets bentonite <br /> Depth to water Z Bags sand/gravel °5 <br /> Mix Ratios 4 yp Filter Pack type/size <br /> Installation Method L_ Surge Block: - ( y/ <br /> Quantity Installed (,b Discussed with geologist: - ((!�/' n ) 19N 5j-Jt- <br /> Type of method <br /> EH 29 29 <br />