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MO t � [NG 4VF_.-L NS'AI-_ <br /> I �.;iCN Rz.?OttT <br /> `9 ( CONS'7RUCTTON <br /> Date: cJ �� <br /> Total DeRC-h <br /> P-em ise Address: /3 176 41' from Sc_ez LezSt.`: (from) 1 Fs (to) S <br /> Filter Pack (from) s- Ct) <br /> o 3 <br /> well No.: �� Bentonite (from) <br /> GroutCfrom) 3 (to) <br /> InsPec:or. Ding ng type C-ME7 S <br /> Agger <br /> Pe_^it No. Como_letion- Stove pipe/c.`z:sae box (circle one) <br /> Delling Company: -U�-� <br /> � � <br /> 3 ca n4 <br /> ♦ he ht <br /> Consultant <br /> Grologist_zlr� A.3CYS-GRcLN CHRz-, !•Scx <br /> CcIfVP 1C.V <br /> CVout)d Sat=$ <br /> S?cr•rat PERNI UT INFO. pcat <br /> Duta^.ce to sewer line fL <br /> Domestic well on site • C Y/ n) <br /> if yes, location and distance - -n• _ <br /> N <br /> <� = 3 <br /> K. G <br /> ted <br /> O <br /> W .I: <br /> f�C.Ot1 Y'" � •� <br /> S?INPLING <br /> Holdir:g T emDerature <br /> Me*hod <br /> Screening Method C v I <br /> Tracking Sheet - y n) _...--L <br /> SPOILS <br /> £ MSA i:R .Aj.S/DEVELOP 'T <br /> Storage \Method <br /> Contamination Noted • C Y n Casing type 2" <br /> Storage Location Blank $ ft. Steen 13 <br /> Slot size .0-2-0 <br /> GRO- :ANGBags cement <br /> // Budkets bentonite L4 <br /> Depth to water �2�l2 Bags sand/gravel <br /> Mix Ratios ' - -u��u' ^� Filter Pack typesize /2. <br /> Ins;allacon tri shod Surge 31ock: - C Y <br /> Disrssed wit's geologist. - C y/ n) <br /> Quaac.'y Installed ---l" Type of method <br />