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MO,ORING WELL INSTALLATION REPORT <br /> Date: 2'Z ' Z CONSTRUCTION <br /> Premise Address: , r Total Depth t — <br /> r Screen Length (from) (to} q <br /> Well No.: N Filter Pack (from), 2`k•5 ,.(to)�_ <br /> Bentonite (from) 8 E (to) <br /> Inspector. Grout (from)_ [a _(to) 01 <br /> Drilling rig type <br /> Permit No. ' o.-6Auger O.D. <br /> - Completion - Stove ' e/cluisne b circle one) <br /> Drilling Company: p <br /> Driller• [ casing <br /> height <br /> Consultant <br /> Geologist^ �&dam __ T <br /> ABOVE-GRCUND CHRM Y-60X ' <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground SurfaceKA <br /> T'• <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - (y/n ) <br /> If yes, location and distance - ft- <br /> mac' <br /> SAMPLING slara i 4 <br /> socticn ;• <br /> 3 <br /> Holding Temperature N D <br /> Method <br /> F <br /> ack <br /> Screening Method <br /> Tracking Sheet - {y/ n } <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT. <br /> Contamination Noted - (y/ n) �,f it <br /> Storage Location Casing type14 <br /> Blank ft. Screen ft. <br /> Slot size . <br /> GROUTING Bags cement <br /> Buckets bentonite M <br /> Depth to water PC Bags sand ate' 1/0,— " <br /> Mix Ratios 1,0qj qO Filter Pack type/size LVL.A <br /> Installation Method Surge Block: - ( y O) <br /> Quantity Installed X Discussed with geologist: - n) <br /> Type of method <br /> EH 29 29 <br /> i <br />