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OONITOpRING WELL INSTALLATION REPO <br /> r �(A �u/ wil/�p 111t e/ <br /> Date: Lg' 9 9 CONSTRUCTION �^ <br /> Premise Address.�'���' �` �� ° { � O L � t Total Depth <br /> Screen Length (from) 41 S (to) a <br /> Well No.: E Filter Pack (from) %5 (to) `� y <br /> Bentonite (from) 58 (to) 5b <br /> Inspector:/ Grout (from) 5t; (to) b <br /> Drilling rig type C S I�wl) -b✓clu_e_ <br /> Permit No. Auger O.D. ?, YLII.D. <br /> AA ^ Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: J <br /> �] Sco+t No�rt�av,`Y <br /> Driller: /// 7 � casing <br /> height —QW7;F <br /> Consultant <br /> Geologist ABOVE-GROUND <br /> CONFLETION CHR*7Y-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Satan <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - (y/ n ) oft-DAW) <br /> ) <br /> If yes, location and distance - <br /> 5(✓P n 0 _ <br /> = o <br /> 4 = • <br /> c <br /> SAMPLING slonad <br /> on <br /> Holding Temperature C� _ <br /> Method P / _41 _ P <br /> Screening Method <br /> Tracking Sheet - ( yl/ n ) <br /> SPOILS <br /> Storage Method-� � � MATERIALS/DEVELOPMENT <br /> Contamination N ted - (y n ) <br /> Storage Location Pr w,e o+ • jt est S16-'04 Casing type c� F�U <br /> SW �r^� o4 Blank___( fr. Screen 25 ft. <br /> Slot size .0')0 <br /> GROUTING Bags cement <br /> Buckets bentonite I - 501 nIJAtvw Chi"pS <br /> Depth to water 67 ' 70 Bags sand/gravel 8 - I00 t b <br /> Mix Ratios Filter Pack type/size 5121 48 <br /> Installation Method 0� _ Surge Block: - (y n ) pro <br /> Quantity Installed Discussed with geologist: - (y/ n ) a�" �a +dk-of <br /> EH 29 29 <br /> 9�{ b Typeofinethod5o!Aeb1OCK <br /> 11/ U 100 <br /> Sc�KS 5 r5 t g �V�ttc <br /> 13asyli k. <br />