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Mor NG M .' NSI -a:CN ooEtT . <br /> FSB / tP� CONS N <br /> Date: (�� C <br /> Total Dep[h to 42 <br /> p-e�se .address: Screen Length (&om) 3� -C ) <br /> Filter Pack urom) —(to) 3 92_ <br /> well No.: Beatonice ($om) 3? (to)_—.--- <br /> Grout (! om)�— <br /> Insoec:or: Drilling ag type <br /> pe Comoledan- StoveBrie box (circle one <br /> Drlling Company- V cas:n4 <br /> Q ♦I� A6 hei5ht <br /> Carsul:aat 41 <br /> Czolog�st /Nowe /r7�et1 a �!.?''=�fCN ^,MP'1C. <br /> cr �i oc n 1: F prod <br /> S?_ 1._ . _P.V4T r0. <br /> r3� � � 8- <br /> Dis:z.ce to sewer line <br /> Domestic well on site - C Y AD �Z8- , A, <br /> if yes, location and distance - <br /> E- '� 3 <br /> K, O <br /> {IOned = e <br /> soclon r, _ <br /> SA-mDUNG padk <br /> 4oldirg Temperature - <br /> Method <br /> Scree:ing Method <br /> Tractiag Sheer - C Y! n) <br /> 70 <br /> SPCILS <br /> �,� /. � c':IALS/DEVELOP!v�+T <br /> Swrage Me hod G l� �it <br /> Contamination Noted - C /0) Casing type i &�^ ty <br /> Storage Locadon 3larrk�—_it Screen z — <br /> Sloc size <br /> Bags cement � a r <br /> GROLT iNG Bucketsbeat <br /> 9 D, Bags sand/gravel <br /> Depth to water Flter pack ype/size <br /> Mlx Rados 4 scree Block: - n <br /> lns:allation Method_ Duct ssed with geology l7r! n)D�Il <br /> Quant y Insralled Type of method �`a �s �n / <br />