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idiTORING'WELL lDISL.ATION REPOn <br /> � "".ml, • -A S" <br /> > <br /> , .,,.,{. -.• �r.+A • Mme..,.� <br /> Date: * `° a CONSTRUCTIONS <br /> "Total Depth <br /> Premise Address: , <br /> 'Screen Length (from) Cto) -- <br /> Well No.: <br /> . _ + rte'. 4 Filter Pack ;-(from) (to) <br /> ' Bentonite (from) !o (to) <br /> * y,. ., Grout (fro .� (to) c.T <br /> Inspector F G <br /> . - �' � y� '�?`•.'�,,Dulling rig type <br /> !� �T 'Auger.O.D. �__�. <br /> Permit No. I.D. <br /> Completion - Stove pipe/christie box {circle one} <br /> Drilling Company: 60 ��-a4, % <br /> Cr <br /> Driller' casing �/�/Ql {/✓ <br /> -.i V7:F <br /> height • ' <br /> Consultant <br /> Geologist ABOvE-GR ND iS"TY46OX <br /> `,o0VPLETCN C t ETiON <br /> r • �`"� °� .�� "*.� .�~ ,z c Cirvund Surface <br /> SPECIAL PERMIT INFO.• y V GT �' IJaa ,,, <br /> ! i <br /> Distance to sewer line . w" ., 1�`,� <br /> tt <br /> Domestic well'on site - (y/n ) 4k ; !vtt <br /> tt.4 <br /> If yes, location'and distance - ' <br /> SAMPLING _; on gmysl pack op <br /> Holding Temperature <br /> Method �' -' �4 :, p2,6,, r <br /> Screening Method k ' <br /> - :-AVE <br /> Tracking Sheet - C Y/.n ) Z =tc. 2 #n <br /> Nt Z7 <br /> SPOILS <br /> - w <br /> MATERIALSigE.VELOPMENT <br /> Storage Method <br /> Contamination Noted - Qn') .5TR0 O�th�• c r � <br /> • •�•' � .. ` " Casing type <br /> �. .t ft. <br /> Storage Locatian_dk/1crtdL_ —t, �Blank – Screen� rye <br /> • _ - r Slot size lam+ <br /> GROU WING .. Bags cement 3 <br /> - w Y�i s `," "� 4 Buckets bentonite� <br /> �: Bags sand/gravel <br /> Depth to water _ - `� Filter Pack type/size �' a .e x <br /> Mix Ratios t – •. Surge Block:'-.(-y lt, 4 <br /> Installation Method <br /> Quantity Installed_ 3 eft-C�- Discussed with geologist: - (Y Q <br /> Type of method <br /> EH 29 29' <br /> IT. <br />