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PY <br /> stc ,C 1� <br /> OINIO. <br /> Date: ,f�- CONSTRUCTION <br /> Premise Address: <� 7 1� �G�� Total Depth o� <br /> Screen Length (from)-'C26 2-10 (to)156 o. I Go <br /> Well No.: Filter Pack (from)�6 (to)� <br /> Bentonite (from)io(o (to) 55 <br /> Inspector. G .`7 Grout (from) 5c (to) n <br /> / Drilling rig type_. <br /> Permit No. al Auger O.D. l I.D. " <br /> Completion - ov christie box (circle one) <br /> Drilling Company �ii �-z'/ / /%Cv'C�o��� �e�I�+'4�`z��S e ar Z/O <br /> Driller: casing <br /> height <br /> Consultant <br /> 7//, <br /> Geologist �✓1`C ��� �`e L( .- <br /> ASOVE-GRCUND CHMM-BOX <br /> COWLEE7ZN COM E nCN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line ��/� grout <br /> Domestic well on site - (y,�n )/ ft. <br /> If yes, location and distance <br /> v• � O <br /> r <br /> SAMPLING .loro.� <br /> aectcn <br /> Holding Temperature <br /> ack <br /> Method = F <br /> Screening Method "c <br /> Tracking Sheet - ( y/ n ) _ <br /> SPOILS <br /> Storage Method r? S - 5 �r�� ��/ MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y (i <br /> Storage Location_ «� £r� `� ��G�) Casing type S <br /> Blank ft. Screen 7 U ft. <br /> Slot size D 3 S <br /> GROUTING Bags cement <br /> / Buckets bentonite <br /> Depth to water / / Bags sand/gravcl <br /> Mix Ratios �' f` 7 / 5%6 f Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ ti ) <br /> Quantity Installed Discussed with geologist: - ( y/� <br /> Type of metliod <br /> EH 29 29 <br />