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MO. .. PORING WELL I REPORT <br /> Date: �- � '� 2 CONSTRUCTION (4k f <br /> Premise Address : 7 � -5 01 NAY/LeSY� t Total Depth &O ( Ui <br /> Screen (from) (to) <br /> Well No. : Filter Pack ) (to) <br /> Bentonite (from (to) <br /> Inspector: �YJGUL�Ss�S �J Grout (from) (to) <br /> y Drilling rig type <br /> Permit No. 1 1 ' 2�� 4 _ Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle on <br /> Drilling Company: <br /> Driller: casing <br /> height �EWT <br /> Consultant I <br /> Geologist fGr <br /> /. ABOVE-GROUND CHRZTY-8CX <br /> lA ( ,FQ(:G(4p j CCM?LETION COMPLEMCN <br /> SPECIAL PERMIT INFO. �� QQ �� end S� �i <br /> Distance to sewer line otos <br /> Domestic well on site - ( y / n ) ft, <br /> If yes, location and distance <br /> tt. <br /> a <br /> c <br /> SAMPLING slottwi <br /> saaJcn <br /> Holding Temperature <br /> Method <br /> Screening Method = <br /> Tracking Sheet - ( y / n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVEI.OPMENT <br /> Contamination Noted - ( y / n ) { il <br /> Storage Location Casing type V `t <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios 24.,70.. -I-a 9O ¢ O Filter Pack type/size <br /> InstallationMe�od 1 Surge Bloch: - ( y / n ) <br /> Quantity Installed Discussed with geologist: - ( y / n ) <br /> 9kw ado �^ �1 ^✓ � n ,luV " Type of method <br /> EH 29 29 0 <br /> i <br />