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N TC3R(((''I+NG WELL INSTALLAMON R-PORT} »e <br /> Wy <br /> Date:--- <br /> f 1{C]{ CONSTRUCTION <br /> Premise Address. - �°� Total Depth <br /> 1 <br /> Screen Length (from) ? (to) <br /> Well No.: "` Filter Pack (from) & (to) <br /> Bentonite arom) L� (to) <br /> Inspector. - -°� ' Groat (from) {tri) 0 <br /> ..,_ Drilling rig type C49`6 ?S <br /> 61 <br /> Permit: to. 0 7 Auger O.D. je 11). 3.9-5" <br /> . Il Completion-- Stove pipelcbristie box (circle one) <br /> Drilling Company: G, t, <br /> 1 casing <br /> Driller.-Driller.- Iv,� ' . height. . <br /> Consultant 40& <br /> 1 � <br /> Geologist ,A90Y'E•GROUNI <br /> u COMF'f.:'?iON CHRSSSY-acx <br /> OMPLE 1C <br /> G ur�d Suface —.�...W... . <br /> SPECIAL PERMIT INFO. <br /> grout <br /> Distance to sewer lute <br /> Domestic well on site - (y/ fL. <br /> If yes, location and distance ! ZIA <br /> {# <br /> . C <br /> slcttad — c <br /> SAMPLINGseclY y- cn <br /> Holding Temperature ��►09� e �+arce` .�t <br /> Method -f-PP- .eeOaxo <br /> �h — <br /> Screenin Method 41&15= — <br /> Tracking Sheer n) <br /> SPOILS ' <br /> Stora e'Method. � Ut4 t .1 ..,�,., . ; ° ; ,. <br /> t $ ... � . - r o s •_., MAT�r2tAi„S/I�EVELf}�MENT� _-�: f <br /> Contamination Noted� � ,; � � ,-c . <br /> . <br /> Scorage Location &X- ijt-,Z ` Casing type c #.� )0/� <br /> T ti Blank ft. Screen ft <br /> Slot si <br /> i .02- <br /> GROUT{NG <br /> Bags cement <br /> ` Buckeu`bentonite °" ., <br /> Depth to water =•` a` . <br /> Mix Ratios. ' Filter,Pack type/size <br /> Installation Method I� � Surge I3toc?t: -'ay n <br /> Quanrc ins;alled--- 11 Discussed with geolo&t;- �t n } <br /> ` <br /> Type of method & k &., 'le" s+4q <br /> 62 7 /,&X 2-) <br />