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MO,,,PORING WELL INSTALLATION REPORT <br /> Date: < <— —9 2. CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) I-� (to) <br /> Well No.: kk Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: r casing <br /> height <br /> Consultant _qV <br /> 7//, T <br /> Geologist •— <br /> ABCVE-GRCUND CHRZTY4= <br /> OONFLETCN CCMPLEnCN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - ( y/ n ) _ft. <br /> If yes, location and distance - �. <br /> it. <br /> = m <br /> C <br /> SAMPLING •lore,! : __ d <br /> aac.cn '— <br /> Holding Temperature <br /> Method = <br /> Screening Method C =_ <br /> Tracking Sheet ( y/ n ) _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />