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r M(�'ORING WELL INSiALI.ATION REPORT <br /> Date: �'Zlp, t CONSTRUCTION <br /> Prem / <br /> Premise Address: �7 ?&y /YoY 12- Total Depth /3.5 <br /> Screen Length (from) /-3 (to) 3 <br /> Well No.: Filter Pack (from) /3. (to) L•S <br /> Bentonite (from) 2.5 (to)Inspector: ^-+�- ����'.�etit- (from) (to) O <br /> Drilling rig type 5(' <br /> Permit No. Auger O.D. 7 I.D. 3 <br /> Completion- Stove pipe/chrisrie box (circle one) <br /> Drilling Company. <br /> casing <br /> Driller. -:F height <br /> Op Consultant <br /> Geologist ABOVr•GROUND \ <br /> gM?Las JCN COMPL CICN <br /> Ground Sufis <br /> SPECIAL PERNQT INFO. <br /> Dista.^.ce to sewer line <br /> Domestic well on site - (y/n) 1 tL <br /> fL <br /> If yes, location and distance - _.�_._ti- <br /> 0 <br /> slotted = c <br /> SAMPLING s+cdon <br /> Gt.t Z:Z: ra& <br /> Holding Temperature — <br /> Method <br /> Screening MethodNu <br /> Tracking Sheet y n) <br /> SPOILS <br /> Storage Method -d"�" MA i"RIALS/DEVELOPMENT <br /> Contamination Noted - ( n) -2- <br /> Storage Location b� �.cA Casing type <br /> Blank ft- Screen L U (- <br /> Slot size Z <br /> GROUPING Bags cement <br /> Buckets bentonite T <br /> Depth to water 3.5 Bags sand/gravel Z 2- <br /> Mix Ratios Filter Pack type/size 3 C- <br /> Installadon Method Surge Block: - &/ n) <br /> Quantity Installed Discussed with geo gis : - O n ) <br /> Type of method <br /> =?.lo 1_3 <br />