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Date: 9./ce. <br />Premise Address: it) ii/d/leit <br />Well No.: -#6,1 <br />Inspector. <br />p ermit 140. <br />Compo_ny: <br />Drfile.r: <br />Consuitar.t <br />C-eolo gist <br />7e" <br />AL. 9 <br />7=1 <br />I 1.• neigh= <br />I <br />ABCVE-GSCX-NO <br />G---rI Scs <br />LLoristd <br />9S) <br />ca.sing <br />MO' sE4rDEING WEI.Thi.STALLATION REPORT <br />SPECIAL PERMIT INFO. <br />Distance to sewer line >50 <br /> I <br />Domestic well on site - y <br />If yes, location and distance - <br />SAMPLING <br />Holding Temperature ,t4 <br />Method (__:ta <br />Screening Method <br />Tracking Sheet - ) <br />SPOILS <br />Storage Method 6 <br />c...,,,r7iroti Noted - <br />Storage Location <br />GROLMNG <br />Depth co water 50 <br />/ <br />Ma Ratios <br />Lnr.ullaton Method <br />Quantity Installed <br />CONSTRUCTION <br />Tonal Depth <br />Screen Length (from) (co) <br />Eater Pack (from) (to) <br />Bentonite (from) (to) <br />Grout (from) (to) <br />Drilling rig type 75 <br />Auger OZ. P LD. I-- <br />Completion - Stove pipe/claristie box (circle one) <br />MATERVISADEVELOPMENT <br />CasMg "type; P <br />Blank 93 Screen___,c____--et. <br />Slot sine 0 0 <br />Bags cement 0 <br />Bucker s bentonite <br />Bags sand/gavel <br />F2t=' rack type/size <br />Surge BLocki - y <br />Discussed with geologist - ) <br />Type of method <br />rf-roi4