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f U61TOWNG WELL INSTALLATION REPO <br /> Date: Aor-C CONSTRUCTION <br /> Premise Address; 06 � r ! <br /> Total Depth .� <br /> /} Screen Length (from) (to) <br /> Well No.---M,W !r Filter Pack 0 (from) (to) ,,� <br /> Bentonite i (from) 17,� (to)_ f o <br /> Inspector, Grout (from) 11 (to) <br /> t .Drilling rig type-- . .- <br /> Permit No. Auger O.D. LD �"� <br /> ` Completion;h Stove <br /> Drilling Cornpan . pi e/ stie (circle one) <br /> L . kj <br /> Driller: EAAA �w casing <br /> � height <br /> Consultant t C'e-A <br /> I— <br /> IN GeologistIf r77 <br /> GQ,�L S ABOVE-GFi0 _ <br /> COWLETION t - COMPiETtCN <br />{ §PECIAL PERMIT INFO. Ir Ground Surf owe <br /> Ing <br /> i Distance to sewer line i Z�j•l I,�jl ;i <br /> Domestic well on site - (y/ n) l it9 <br /> If yes, location and distance - r f r Z <br /> t. M <br /> SAMPLING <br /> on <br /> Holding Temperature <br /> Method (Q = R"1°I F <br /> Screening Method_. f�( — <br /> Tracking Sheet - n <br /> ( / ) <br /> it <br /> SPOILS <br /> Storage Method MATER IALS/DEVELOPMENT <br /> Contamination Note�- y <br /> EI 6 1i <br /> .Storage Location i Casing type II Pvc <br /> Blank E175 ft. Screen Z ft. <br /> Slot sizeII R b2O <br /> GROUTING Bags cement Ib <br /> .[� Buckets bentonite CQ 19L)cket <br /> i1 ih <br /> Depth to water. 1 •� Bags sand/graveI Z F <br /> Milt Ratios 4 fql) 1 �`1 v' Filter Pack type e <br /> Quantity 8 y n ) <br /> Installation Method CWUl _ Sur a Block: r <br /> uanti Installed Discussed with eologist: -0 n ) <br /> EH 24 29 Type of method d r <br /> i <br /> Ji <br /> a <br />. � j� it , <br />