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MWORING WELL INSTALLATION REPORT _ <br /> Date:_/ l �Y CONSTRUCITON <br /> Premise Address?/` `N d ✓f/ Total Depth <br /> Screen Length (from)—(to)- <br /> Well <br /> from) (to)Well No.: Filter Pack (from) - (to) <br /> Benronite (from) (to) <br /> Inspector. S S / Grout (from)-(to)- <br /> Drilling <br /> from) (to)Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/clu-isue box (circle one) <br /> Drilling Company: <br /> Driller: cae i.nq <br /> 7M � height <br /> Consultant_ ���1 <br /> Geologist <br /> ABCVE-GACUND t 4i1STY 30X <br /> CCMPL�flON CCMPLE=nCN <br /> SPECIAL PERMIT INFO. Ground Suiaca <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) --!t <br /> If yes, location and distance - ft. <br /> r <br /> C <br /> TV = O <br /> SAMPLING slored = <br /> aceicn = <br /> Holding Temperature — yTavel Pads <br /> Method — <br /> c <br /> Screening Method <br /> Tracking Sheet - Cy/ n ) <br /> __ . <br /> ft. = tt. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ ) <br /> Storage Location Casing type <br /> Blank h. Screen fr. <br /> Slot size <br /> GROUTING Bags cement <br /> J Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Rados 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 />