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ENVIRONMENTAL RESOURCEMANAGEMENT <br /> ERM—WEST <br /> FIELD WELD`,COMPLETION FORM *C1HRISTY BOXJob 111 i <br /> Noma S �I�'1 Owner. (.fin i `-rr LOCKING STEEL COVER ! <br /> �1 17r,c T1`C.. . <br /> y -..CINCH DIAMETER <br /> Location O tfii<t Job W. STEEL,CONDUCTOR <br /> Logsed we <br /> � Revied , T 1 �r-� ,/ i <br /> sr '----k Br. . 1��/� Manager CASING <br /> �igSyy S Ti t to I� j <br /> Well I b`INCH DIAMETER <br /> Number. M W Driller. f - i BOREHOLE <br /> y( -o—tox fent <br /> Date of Installation: Hours Drilled; I� <br /> ENTONITE-CEMENT <br /> Equipment f SEAL OR <br /> U15--Inch Hallow Stem Auger inch Rotary Wash i SSACK CEMENT-SAND <br /> Gallons of water SEAL TT i <br /> Used During Drilling: Gallon ��- t0? (Mt <br /> Gallons: j <br /> I <br /> Method of Decontaminationf� J � I <br /> Prior to Drilling: J G4 Wl c-1 J ` TOP OF CASING AT <br /> Permit 0: FEET ABOVE/A171 <br /> Permitw Ltsaing Agency�G r1 �oap[tr`vl Ll[ -FT; cf 4fgjMGROUND LEVEL <br /> DEVELOPMENT s` NCH DIAMETER i <br /> f Method of BOREHOLE <br /> Development , I�, 0 LO SQ fee[ <br /> Development INCH DIAMETER <br /> Began Time SCHEDULE 40 PVC <br /> BLANK CASING <br /> Depth to water 5 <br /> Before Development Fat '� �`z to>r• feet <br /> BENTONITE-CEMENT <br /> Yield: C. Time: tr~ EAL OR <br /> PM T°ur To 8-SACK CEMENTSAN0 <br /> Yxld Time Date: SEAL <br /> GPM <br /> From: To <br /> Total Water Removed 0-1—�— to 3� feet E <br /> During Development Gallons BENTONITE PELLET <br /> >- ST�EAL <br /> Description of -I_ <br /> Turbidity at End Clear Q Slightly cloudy <br /> of Development [] Mod Turbid Q Very Muddy r !� <br /> w� t wur�swl <br /> Odor of Water. SANPACK <br /> � 5Z,Water © Ground Surface Il to-�Lfeet <br /> �Tank Truck <br /> Discharged 1=Storm SewersINCH DIAMETER <br /> TO 1�Drums =storage Tank <br /> 0 Otho SLOTTED I D.olo i <br /> ch1 SCREEN <br /> Depth to water DateTme <br /> After Development Feet well Development Complete: }' S to.L ' feet <br /> Well Elevation <br /> Feet...__,..Measuring Point(Le LINCH DIAMETER Top of Casing_ <br /> SCHEDULE 40 PVL <br /> MATERIA ! j <br /> ��� �+ /fBLANK Si LT TRAP <br /> Sacks of Sand to��feet <br /> sacitt ofCement 4 <br /> BorraM WELL CAP <br /> Gallons of Grout Used � <br /> HOLE CLEANED OUT TO h <br /> Sacks of Powdered Bentonite I ft�t <br /> pounds of Bentonite Pellets ! y BOTTOM OF BOREHOLE <br /> Feet of Inch PVC Blank Casing <br /> Feet of Inch PVC Slotted Screen <br /> NOT TO SCALE r <br /> Feet of Inch Steel Cooducmr Casing <br /> Yards Cement-Sand(Recti-Mix)Ordered I ADD1Tf ONAL INFORMATI ON: <br /> —Yard'Cement-Sand(Recti-Mix)Used <br /> Concrete Pumper Used? No Yes <br /> i� <br /> Name it <br /> Well Cover Used: Locking Steel Cover <br /> Diversified Well Products Box <br /> Christy Box I <br /> ��Other I jf <br />