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LIO' BRING WFri.l..I�iSiALI,.a T i0N RF_PO1tT <br /> Date: CONSTRUCTION <br /> �g 20 I <br /> Premise Address: 7O Tow Depth <br /> -i '�'`a 9 <br /> A Screen Le.Zgth (from) l9 (to) <br /> Well No.: / •L'/J Zt Filter Pat's (from) (to) 7 <br /> Bentonite (from) 7 (to) -S <br /> Inspector. <br /> Grout (from) 5 (to) c�, <br /> Drilling rig type -S3 <br /> f <br /> Per tit No. Z Auger O.D. z I.D. <br /> Completion - Stove pipe/chestie box (circle one) <br /> Dr,Iling Company- <br /> ♦^ T cas,ng <br /> Order: I T he-ight <br /> Consultant ^+ i <br /> .� <br /> Geologist ,t5CV=-vACUND V-RiS-IY-aCX <br /> Ground Stz}aca <br /> SPEC!A-T ?E,'4-WT INFO. t pt <br /> I <br /> Distance to sewer line A� ♦ S ft. <br /> Domestic well on site - ( y 4 ?t. <br /> if yes, location and distance <br /> -- o <br /> S��toLiNG &*=on <br /> vlvw Pack <br /> Holding Tem ereatusre <br /> Method <br /> — <br /> Screening:Method oN r: <br /> Tracking Sheet y n ) <br /> O <br /> SPOILS <br /> Storage <br /> Method �� 7'� MAi'.PjALS/DEVELOPkENT <br /> Contamination Noted - (y/ n )--,t t3TcrJi s� ��4n /- <br /> Storage Location dh At� Casing type <br /> Blare-k 9 ft. Screen /o _ fr- <br /> Slot size o 0 2 <br /> GROUTING Bags cement = 3 <br /> Buckets bentonite <br /> Depth to water = l0 Bags sand/gravel <br /> "vtix Rados P 9 �d t 19'� G-.� 65 ' Filter Pack type/size "/C <br /> Installation vtet.'zo Surge Block. - ( y/&j <br /> Quandiry Installed = � w Disci-used with geologist: - (y/0n <br /> Type or method <br /> 7 - �3 AW 2-114 <br />