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i�. LPOFL-�.1 <br /> Date: Noll CONSTRUCTION <br /> Premise Address: Vs Total Depth <br /> cre'en Length (from) x k "(to) <br /> Well No. J /�++w�� Ul�l ' Filter Pack (from) (to) <br /> 1 Bentonite from (to) <br /> Inspector: w . Grout. o (to) <br /> Drilling rig type I <br /> Permit No. Auger O.D. I.D. <br /> f ' Completion - Stove pe/christie box (circle one) <br /> Drilling Company: <br /> Driller: . . ; caging t <br /> A �; height- . <br /> Consultant L$bi <br /> r Geologist <br /> ABOVE-GROUND <br /> A COWPLErION c,HRL5TY-BOX <br /> COMPLEnCN <br /> SPECIAL PERMIT INFO. 1 ' Ground Surixt 4 <br /> i t . <br /> Distance to sewer line out <br /> Domestic well on site - (y/ n ) <br /> h' <br /> If yes, location and distance - <br /> ft. <br /> CD <br /> C <br /> A <br /> OD <br /> C <br /> SAMPLING $!c <br /> j ADL ° <br /> Holding Te er ture Y <br /> Method D ,ilt ! ; <br /> Screening Method <br /> Tracking Sheet - n ) <br /> ft <br /> y/� s�. w 11. <br /> SPOILS <br /> Storage Method MATE RIALS�DEVEL.OPMENT <br /> Contamination Noted - qOV nN <br /> Storage Locatioe� Casing type U <br /> BIank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> i Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Instal tion Method Surge Block: - ( y/ n ) <br /> Qua tity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method M <br /> 4., <br />