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ERM WRST NTAL RESOURCES MANAGEMENT <br /> ttGHRISTY BOX <br /> FIELD WELL COMPLETION FORM (3 LOCKING STEEL COVE <br /> jobth `� L '7r L tiI Owner c�7- INCH DIAMETER <br /> Name. -7— <br /> - S`7 !!'t` - Trac 37 f 0 CASING ONouCTOa <br /> job aw CASING <br /> Locauoa <br /> Reviewed Project f' grondy, to foot <br /> By.Log. <br /> By Maaagar /vCC[ <br /> INCH DIAMETER <br /> WallGLL ru e- tc, ,�I BOREHOLE <br /> Number '- • c Driller to feet <br /> Data of Instdiatmn._/ Z 9-OT-) _ Houta Dr Uc& SENTONrre-cEMEwr <br /> SEAL OR <br /> Equipment BSACK CEMEiNTSANO <br /> Each Eiallow Stem Anger Inch Rotary Wash SEAL <br /> Gallons of Water `V to toot <br /> Lased During Onllrng: Goons: <br /> Method of DacoataxamattonC�� r TOP OF CASING AT <br /> Prior to Dnlling. C�7 ( -#� _ _ _ _ 0`2FEET A8GVEJATJ <br /> Weil Permit rte issuing Agency /-h UDciyGt r OUND LEVEL <br /> INCH DIAMETER <br /> DEVELOPMENT BOREHOLE 1/� <br /> Method of fn�to_L feet <br /> Development: <br /> - INCH-DIAMETER <br /> Development SCHEDULE d0 PVC <br /> Began Date Tim= BLANK CAS�I4G <br /> Depth to Waters s"` fnot <br /> Before Development Feat <br /> 81~NT4NiTE-CEMENT <br /> Yield Time: Date: SEAL OR <br /> G M To 8-SACK CEMENT-SAN <br /> Yield. Time: Date: 'S� <br /> GP'+Af rr <br /> From: To f/ �. to leer <br /> Tool Water Removed BENTONITE PELLET <br /> During Development Csallons SEAL <br /> pmgsotson of 2 S to-;Z`7 feat <br /> Torhsdsty at EndClear Q Slightly cloddy <br /> of Development Mod Turhtd Q Very Muddy w..rs Nu..esw <br /> SA PACK <br /> ddar of Water to�feet <br /> Water Q Ground Surface Q Tank Tritek INCH OI AME TER <br /> Discharged Q Storm Sowers OStosxge Tusk <br /> TO: ©Drums Q Other SLOTTED( dip <br /> inchl SCREEN <br /> Depth to Water Date/rima to-,I?—feet <br /> After Development Fact Weil Development Compfew <br /> INCH DIAMETER <br /> Well Elevation:— Feat .Measuring Point(t e.Top of Castagk SCHEOULE by PVC <br /> MATERIALS USED BLANK RANK Sl�TRAP <br /> I _lto J `'_!fees <br /> Sacco of Sand <br /> Sacks of Cement3?TTOM WELL CAP <br /> Efact <br /> Gallou of Grout Used HOLE CLEANED OUT TO <br /> Socias of Powdered Beawfute feat <br /> Pounds of Bantootto Pellets BC�ZTOM OF BOREHOLE <br /> Feet of lath PVC Blank Casing L fwt <br /> Feet of Inch PVC Slotted Screen NOT TO SCALE <br /> Feat of Inch Steel Conductor Casing <br /> ADDITI ONAL INFORfIRATION: <br /> Yards Cement-Sand(Recti-Mot)Ordered <br /> Yards Cement-Sand(Rads-MIX)Used <br /> Concrete Pumper Used? No Yrs <br /> Name <br /> Well Cover Used. Locking Steel Cover <br /> Diversified Well Products Box <br />