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9 <br /> `ate: CONSTRUCTION <br /> Premise Address: 3ia&L6. Total Depth_ <br /> Screen Length (firom)__Je.O <br /> Wel! No.: Fater Pack <br /> (from)�Q.�(to) D�_ <br /> Inspector. Bentonite (from)_ fo.0 (to)_$.D <br /> Grout (from) 0,{}„_(to) r <br /> Drilling rig type <br /> Fermis No. ~Anger O.D. O' " I.D. ' <br /> Completion -Stove pip irisae ox (circle one) <br /> Drilling Company;_ <br /> �. DrnlIer. re2rP casing <br /> height <br /> Consultant5 rJ ENv)Ro <br /> jgMp- T <br /> ur NsVt.T-#3k•N rS <br /> Geologist _ � _ <br /> ABOVE-GROUND <br /> COWLEMN CKitM-80X <br /> 7 AWAL PERMIT IPTG©. Grwnd 5�xiscv COMPLEnON <br /> Distance to sewer line. 10 0__ ee�- t__ _ grout <br /> Y Domestic we!! on site - (y/ <br /> is <br /> [f yes, location and distance . IJ9- ii. <br /> 1o.D ft. ' <br /> SAMPU _ a <br /> : t <br /> BIG a4 3 <br /> iry Q am, Inn <br /> Holding Temperature <br /> tw Method Stl Pent <br /> Screening MethoPQU <br /> l. w — <br /> Tracking Shcet - {0/n ? . <br /> Ia SPOILS <br /> �Storage Method Igg Ck&s+- [ TERIALS HVELOFMENT <br /> Contamination Noted - {y/D <br /> Storage Locatio 12n-fiileCasinstype SCh. 40 $VC- <br /> f Blank ft. screen T T.O � , <br /> Slot size D 01 Q'` <br /> 11GROUTING Bags cement <br /> Buckets bentonite I <br /> 'Depth to water S. Hags sand/gravel wiix Ratios o A ' Filter Pack typesize <br /> Installation Method v� Surge Block: - G /n) <br /> Puantity Installed Discussed with geologist: - (©/n) <br /> Type of method .5y <br /> 0929 <br />