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n►vava avevnv rxaa.�.uroaeus.+raavav sv..r vitia, _ - - - <br /> ate: q q CONM—UCn0N <br /> Premise Address: Total Depth--- --------�'-- <br /> Screen Length (frorn) -----(L°) <br /> DnJ@ Filter Pack (from) <br /> Well No.: Bentonite Ororn) (to)„ <br /> Grout (froth) 0.O (to) D <br /> Inspector: X14}( r+ DrnMing rig type m <br /> Auger O.D._ t it I.U. S' r, <br /> permit No. �. Completion -Stove piped e o (circle one) <br /> Drilling Company: k <br /> casing <br /> Driller. -e" Ealdn height <br /> Consultant <br /> CO NsvRT A O TS <br /> w <br /> Geologist ABOYE4ACUND CK7Y-BOX <br /> roompt T)ON WIMPLEnON <br /> t3ttxJM S1dt� <br /> �DR[!fJ►f E T INFO <br /> grout <br /> Distance to sewer line„ Ylti.�� �¢'0 . �L <br /> W_ Domestic well on site - (y/Q) <br /> If yes, location and distance- �+ <br /> J <br /> a <br /> • P. AMl'i 1NG yi, n <br /> o P4W* <br /> Holding Temperature <br /> Method 1,4 <br /> Screening Method <br /> "Tracking Sheet <br /> 2. <br /> `a1 Iwr� 4 <br /> SPOT <br /> Storage Method <br /> �.ATERIALSLn LOPMEN'C <br /> Contamination Noted - (y!n Casing types -U <br /> 6Storage Location Blank f3__.�__n_----ft. Screen,_ <br /> Slot si <br /> v*! ze- /1•r3 i P] - <br /> GR LMNG Bags cement <br /> Buckets bentonite <br /> c 4h to water Bags Sand/gravel <br /> € P Filter Pack type/siza <br /> `Mix Aatios ` Surge Block:- 0/n) <br /> 'Installation Method Discussed with geologist: - l n) <br /> Quantity Installed Type of method <br /> 19 29 <br /> t%d <br />