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Date: <br /> CONSTRUCTION <br /> Premise Address: <br /> Total Depth <br /> Well No.: Screen Length (from)' (to) <br /> Filter Pack (from) (to) <br /> Inspector: Bentonite' (from) (to) <br /> Grout (from) (to) <br /> Permit No. Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Company: Completion- Stove pipe/chnstie box (circle on <br /> Driller: <br /> casing <br /> Consultant height <br /> Geologist <br /> ABOVE-GROUND <br /> CO w LET{O N C,HR Z-TY-BOX <br /> SPECIAL PERMIT INFO. COMPLETION <br /> Ground Surfxs <br /> Distance to sewer line <br /> Domestic well on site (Y/n <br /> - proof <br /> ) <br /> If yes, location and distance <br /> SAMPLING <br /> Holding TemperatureOn <br /> Method - V'V'Eq Pack <br /> Screening Method = <br /> Tracking Sheet - (y/n) _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location <br /> Casing type <br /> Blank ft. Screen ft <br /> GROUTING Slot size <br /> Bags cement <br /> Depth to water Buckets bentonite <br /> Mix Ratios Bags sand/gravel <br /> Installation Method Filter Pack type/size <br /> .__... <br /> Quantity Installed.. Discussed with geologist: - (y/ n ) <br /> EH 29 29 Type of method <br />