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. 1i'ORN, -:ELL, icgd,°; at— p, r!00r r <br /> 31 <br /> "] S Z�iv- <br /> Date: % � I .� d— e � �_ CONSTRUCTION <br /> Premise Address : _ t S�r6t� Total Depth ?SCS„ov'(thl' p/V <br /> e^Ye INd1 e 1 DpfoVjj S+. Screen Length (froth) (to) � S ` <br /> Well No. : . rilter Pack (from)”. d '` <br /> 1 )1 is Bentonite (from)'? (to)��' <br /> Inspector: "60 bf ll/I �jon -u� ( Lti-y-� �i7j�� rLR ? a Grout (from) _ (to) -5 <br /> / ! Drilling rig L'PeMPermit <br /> r� <br /> No._ � 16 ZI �� Auger O.D._ JS " _ 25Completion - Strove. Pipe/ (circle one) <br /> Drilling Company: Wp �/Afn <br /> Driller: lvz � del r,, r �6.f Le f casing <br /> rn &JAL <br /> StiL4�gov <br /> consultantJ)dV0 t�an- a <br /> Geologist V116 VeVA i f I^ <br /> a__Y? <br /> ; <br /> C,Nf-llS -DC7 <br /> SPECIAL PERMT INFO. <br /> / ecat <br /> Distance to sever line_M <br /> Domestic well on site e ( y <br /> If yes, location and distance <br /> V� <br /> 1 NvD S� 1(i+ . alru nt -- <br /> SAMPLING cep, Qp Q nlonsd <br /> cn <br /> Holding Temperature <br /> Method <br /> Screen ng Method _ WN <br /> Tracking Sheet e y n. <br /> SPOILS I� MNAIV ben 4tw4vt <br /> Ch � S v�eiafPd <br /> Storage Method Ss �90 rvm5 MATEWALS D VEI.OPI�iENT <br /> Contamination Noted ( o / n ) OrFKO� � tmPtfl, U Se'yl S <br /> Storage Location__..gh,x U �' n �r Casing type PVC 400& <br /> Blanik '6/4r Pc. Screen 5 ft. <br /> 1111 lea A . Slot size _ 0 . 026 ° _ <br /> GROU11ING L Bags cement 42 7 4 — <br /> b�1 �4 15 Buckets bentonite—L.-64 yam_ <br /> Dept to waterj ' o2S S��d i v _ 1 Bags sandJgravel _ <br /> Mix Ratios..- /Qx 7 � filter Pack type/size eew G dryRY <br /> Installation tvlethod _ _ fa ,1 4Wj2PO ) t's/ Surge Block: - ( y / n <br /> Quantityinstallr_ d __a � _ u _ d /, �` / d Discussed with geologist: On ) <br /> EH 7,429 g Type <br /> �� oddf��metizod_��_(�__�� QD <br /> � G� Ct / / 6L � GYaVI LddS Yv1RO�. !lYQYI <br />