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ENVIRONMENTAL RESOURCES MANAGEMENT <br /> ERM-WEST )!fCHRIM BOX <br /> FIELD WELL CONCPI.Y;TION FORM <br /> Job ``__ ' I Q LOCXING STEEL COVER <br /> Name: -7�tr! `� L am/ C Owner �tilZ- 1/t INCH DIAMETER <br /> Locauoa� l��" fit'- Tr i 337`7• i t� STEELCONDUCTOR <br /> Iab�w g _ CASING <br /> Lagged <br /> 1$� RBeview�edTE�� Project Aadnlx to facts <br /> Y Y Manager 1�� Y <br /> we" INCH <br /> DIAMETER <br /> BOREHOLE <br /> Number M io " Dnlleryrm frt <br /> Dace of Instait don: Hours Dniled; BENTONITE-C€NIENY <br /> SEAL OR <br /> Equipment: SEAL. <br /> Hodow Stem Auger Inch Rotary Wash MACK <br /> CEMENT-SAND <br /> Gaiiaas of Water to Ears <br /> Used,During Drilling ! GaiIour <br /> Method of Deconti m coition5 TOP OF CASING AT <br /> � <br /> Prior to Drains: _ ��rc C 1wIL ^ -. --- <br /> C- 0`'2�FEET A8OVEIATJ <br /> Well Parrott ar d l3 5-0 9 Issuing Agency�e K T 4Q&�1I 6t4>q OUND LEVEL <br /> DEVELOPI4awr ^^T� � INCH DfAII ETER <br /> BOREHOLE <br /> Method of Q to_1 V fees <br /> Development: <br /> Development SCHEDULE <br /> DIAMETER <br /> SCHEDULE 40 PVC <br /> Began Date: Times BLANK CASING <br /> Depth to]Vater ' t4 fee, <br /> Before Deveiopmeat Feet <br /> BENTONITE-CEMENT <br /> Yield. Time: Date: SEAL OR <br /> =PMFrom: TO SSACK CEMENT SAND <br /> • Yield: Timm Data SEAL <br /> GP's[ From: To eLL <br /> to 2 feet <br /> Total Water Removed BEI+ITONITE PELLET <br /> Dieting Davelopmeac Gailorn . SEAL <br /> Description of ;7--5- to f e at <br /> Turbidity at End Q Clear © Silghuy cry <br /> of Development Q Mod.Turbid Q Very Muddy - <br /> SA7Ily�p PACK <br /> Odor of Water T,toZLC..,feet <br /> Water 0 Ground Surface Q Tank Truck <br /> Ditehargod 0 Storm Savers pStorage Tank INCH 09AMETER <br /> TO: =Drums p Ott SLOTTED I ©•00` D <br /> Depth to Waterfeet <br /> Da`°n'"Q° inch) SCR EEc�N <br /> After Developineat Feet Well Development Completes to , <br /> Wed Elevation Feet Measuring Point(i e.Top of CasingINCH DIAMETER <br /> SCHEDULE 40 PVC <br /> MATERIALS USED 13LAANK SILT' TRAP <br /> d <br /> Sachs of � 1 to 'sfees <br /> San <br /> B TTOM WELL CAP <br /> Sacks of <br /> Ccmeat �,3Y5-feet <br /> Gallons of Grout Used <br /> ROLE CLSAI+lEi7 OUT TQ <br /> Sada of Povaieied Bentanirn feet <br /> Pounds of Reatonite Pellets 135TOM OF SOR9HOLE <br /> Feet of retch PVC Blank Cana% feet <br /> Feat of rneh PVC Slotted Screen NOT TO SCALE <br /> Feat of Inch Steel Caiductor Casing <br /> ADDITIONAL INFORMATION:Yards Cement-Saari(Rede-Mix)Ordered <br /> Yard=Cement-Sand(Rede»ih a4 Used <br /> Conerato Pumper Used? No Yes <br /> Name <br /> Well Cover Used: Locking Steel Cover <br /> DiverstFted Well Products Box <br /> Christy Box <br /> Other <br />