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MG...PORING WELL INSTALLATION REPORT <br /> Date: 2 1 D - Z CONSTRUCTION <br /> Premise Address: j�PsJ CO h Total Depth <br /> Screen Length (from) 2 (to) 21 <br /> Well No.: L( 2-4- W - Filter Pack (from) (to) 1 q .S <br /> Bentonite (from) I q. (to) 1-1. 9, <br /> Inspector: '�s. SC�> _ �— Grout (from) I"1. (to) •0-_ <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/ iristie ox (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> 7- height <br /> Consultant I 'd <br /> 7//, 9- -QV-f <br /> Geologist C6�t� bo�(2-�L •- <br /> A80 .GACUND C4�SISi'Y-BOX <br /> CONFLEMN COMPLrcT1cN <br /> SPECIAL PERMIT INFO. Grourd Surface <br /> Distance to sewer line I�,(� grout <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - ft. <br /> ft. <br /> M <br /> oC <br /> SAMPLING dor�.i <br /> s#c1cn =_ <br /> Holding Temperature <br /> Method __ Pack <br /> Screenin; Method ,r — <br /> Tracking Sheet - ( y/ n ) <br /> ft. "= = ft. <br /> SPOILS <br /> Storage Method C)f MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location ©I-I U-)u _ Casing type 4'� ��[✓ <br /> Blank 2 F ft. Screen ft. <br /> Slot size O.OI l7 <br /> GROUTING Bags cement <br /> i Buckets bentonite t <br /> Depth to water 20. Bags sand/gravel <br /> Mix Ratios 3.°5 Filter Pack type/size 2 12 <br /> Installation Method 1 .q)-621,f-"L C Surge Block: - ( y ID <br /> Quantity Installed Discussed with geologist: - ( y 60 <br /> Type of metliod <br /> EH 29 29 <br />