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�'- �.�cfio►�' l'r so <br /> LO ZTALLATION REP(_,.., <br /> Date: , if CONSTRUCTION <br /> Premise Address:FV Z�_ ! a �,� Total Depth_ <br /> ��kJ _,�' a Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (fro (to) <br /> Inspector: Grout (fro ) (to) <br /> S2�Z Drilling rig type <br /> Permit No. 3 Auger O.D. I.D. <br /> �"' Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> � height <br /> Consultant 4 <br /> Geologist <br /> ABOVE-GROUND <br /> COWFLE-NON CHRISTY43OX <br /> (fowl d auto $ COMPLETICN <br /> SPECIAL PERMIT INFO. Ground Sur{ace <br /> Distance to sewer line L,,,k.-- 1VI1 f10 grout <br /> Domestic well on site - (y/ n ) I Ly <br /> If yes, location and distance - ft. <br /> ft. <br /> Al �Z3� <br /> 1*0 <br /> — m <br /> _ <br /> SAMPLING = ° <br /> •lotted — � <br /> aoc�on — <br /> Holding Temperature <br /> Method = 71"'W Pack <br /> Screening Method = <br /> Tracking Sheet - ( y/ n ) _ <br /> ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type X/ <br /> Blank %Z ft. Screen ft. <br /> Slot sifen <br /> GROUTING Bags <br /> Bucknite <br /> Depth to wat `� Z 0 �� BagsvelMix Ratios tea. Filtere/size <br /> Installation Method Surg ( y/ nQuantity Installed l�� Discuh geologist: - ( y/ nTyped <br /> EH 29 29 <br />