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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 one <br /> Driller: <br /> casing <br /> Consultant height <br /> Geologist - <br /> ABO VE-G R OUND <br /> co&FLET{ON CLiRZTY480X <br /> SPECIAL PERMIT INFO. COMPLEfiON <br /> Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) <br /> If yes, location and distance <br /> m <br /> SAMPLING <br /> slatted — c <br /> Holding Temperature ►aeon <br /> Method v2,s4 pack <br /> Screening Method <br /> Tracking Sheet - (y/n) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location Casing type <br /> Blank ft. Screen ft- <br /> GROUT7NG 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 /> ..._..--__l _._.. .. -------.---._Surge.Block:—(.y_/_n_)-- <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> EH 29 29 Type of method <br />