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MOP -)RIN(:; Wc-U INSiAIL4TION R--aORT <br /> -)ate: CONSTRUCTION <br /> �` .C1G��i� / Total Depth <br /> ?-emise Address: Screen Length (from) /-S` (to) _ /O <br /> Well No.:. 11Gy,3 Filter Pack (from) !s (to) <br /> Bentonite (from) (to) <br /> Grout Cfrom) (to) <br /> inspector: Dulling rig type <br /> Auger O.D. o I.D. <br /> ?emit No. / Completion- Stove pipe/chr'-stie box (circle one) <br /> Drilling Company: <br /> height <br /> Driller. � � 7- height <br /> Consultant7/1' <br /> 1 <br /> L�/A/ � A OYE,3AC UND CHS-1 Y-3CX <br /> Geologist - ,,_-i ICN <br /> CiMPt._=+tCN <br /> Ground Suiscs <br /> SPEC!A. ?ER2MIT INFO. pra.K <br /> Dis.arc- to sewerLine /✓/4 h• <br /> Domestic well on site - y n) n- <br /> if,yes, !ocadon and distance - � <br /> ..•t3. ; — <br /> Zux.Q.� it1�^J� �,:. <br /> 1 -a <br /> tw <br /> stod o <br /> S,*IoLIVG soonIM <br /> Holding Tempe tore <br /> Method 4� <br /> Scr eenting Method <br /> Tracking Sheet y n) Ls tt• V � " n• <br /> SPOILS <br /> Storage Method fx f &4 MA—RIALS/DEVELOPk'F-?V'T <br /> Contamination Noted - / n) TCasing type g 140Py-e <br /> Storage Location Blain ft. Screen -� fr- <br /> SIot size <br /> CROUTiNG Bags cement <br /> Buckets bentonite ? ' <br /> Dept's to water :z 7,x. � Bags saad/gravel <br /> MLC Rati05 s ff t •3" Filter Pack type/size <br /> Installation viecho _ Surge Block: - C Y/@) <br /> Quantity Installed 9 3 Discussed with geologist: - (y/ n) <br /> Type of method <br /> v W3 10 -21-13 /'�9� 5 <br /> .5 5 <br />