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iP <br /> (..JNITOR.ING WELL INSTALLATION REP <br /> Date:_ q _ . <br /> CONSTRUCTION <br /> Premise Address: ? IO 0 1 b Total Depth _ <br /> Well No.: Screen Length (from) 1 7 (to) <br /> i Filter Pack (from) 7 (to) <br /> . �/GQ Bentonite. (from) to <br /> Inspector, <br /> ��� Grout (horn) S (to) C� <br /> Drilling rig type <br /> Permit No. Auger O.D. <br /> S cj�` , p _ Completion - Stove pip cluisde'box le one) <br /> Drilling Company: JP xl� ( wyr� <br /> Driller: /\� <br /> height <br /> ght <br /> rT he , <br /> Consultant �/t N I T/1 <br /> Geologist #� > • - <br /> ABOVE-GROUND GiA75TY BOX <br /> COMPLETION COMPLETION <br /> PECIAL PE IT INFO. Ground Surtaes <br /> Distance to sewer ' e grout <br /> Domestic well on sit (y/ ft. <br /> If yes, location and dist. c - ft- <br /> R. <br /> .•A = — m <br /> n Y <br /> y0- <br /> c <br /> SAMPLINGslored <br /> e• _. = o <br /> soden — <br /> Holding Temperate re <br /> Method <br /> Screening Method+7 <br /> Tracking Sheet - (y/ n ) <br /> ft. = ft- <br /> SPOILS II n <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination No ed • n) <br /> Storage Location II Casing type <br /> Blank 7Q ft. Screen lb ft. <br /> Slot size D.c: <br /> GROUTING - Bags cement <br /> t Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installadon Method Surge Block: - (y/ n ) <br /> Quantity Installed ii /�. Discussed with geologist: - (y/n ) <br /> EH 29 29 IVA+ (YVV -414 �/ /0 Type of method t <br /> u>i'- __j o� <br />