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I 1YTOPJNG WELL INST.V-T-ATION REPORT <br /> Date: CONS I"RUCI'i0N <br /> Premise Address- Tota! Depth <br /> Screen Length (from) (to) <br /> Weil No.: F�:iter Pack (froto). (to)_ <br /> Bentoaite (from) (CO) <br /> inspector. Grout (froth) (to} <br /> Drilling rig type <br /> ?e:rnit No. Auger O.D. I.D. <br /> Completion - Stove pipe/clurisde box (circle one) <br /> Drlling Company: <br /> Driller .Y_, casing <br /> 4 I � he,cht <br /> Consultant <br /> Geologist itgCv�-ti�C�'�tCl 1� <br /> C.cWr .EMN Ct i15�Y 30X <br /> SPECIAL PE'R-MI'I' !NFO. C rxl Suixs <br /> I <br /> Distance to sewer line 1 <br /> Domestic weil on site - ( y/ n <br /> if yes, location and distance - 71 <br /> — v <br /> SAMPLING itara.i <br /> Wolding Temperature Sn <br /> Method — <br /> Screenino Method — <br /> Trackir:g Shcet <br /> SPOTiS <br /> Storage Method VfA7EtUALS/DEVEI.QPMEN7 <br /> Contamination Noted - C y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen <br /> Slot size <br /> GROLT7NG Bags cement <br /> Buckets bentonite <br /> Deoth :o warenBags sand/gmvef <br /> Mix Ratios Filter Pack typesize <br /> instailadon -Machod Surge Block: - ( Y/ n ) <br /> Quartiry [nsmilcd Discussed with geologist: - ( y <br /> Type of n=hod <br /> 49 29 <br />