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1 iCNI`3'OhING,, WLI.i,INSTAlal-KEON RCPO° <br /> i d <br /> CONSTRUCTION <br /> Date: <br /> { � G � Tata] Depth <br /> Prernise Address. r <br /> w` Screen Length (from) (to). <br />' <br /> Well No.: �` Filter Pack (from) (to). <br /> Bentonite (&am) <br /> Inspector: Grout (from). (to) <br /> Drilling rige_ <br /> Permit I�Io. <br /> Auger D.C. I.D. <br /> Pe <br /> Completion - Stove pipelc stie box (circle one) <br /> ]Drilling Coropany: y <br /> ,o <br /> T�.., .�;.- L casing <br /> ]driller: <br /> height <br /> Consultant 4? <br /> { eolog�st �' .G NIS CONPLEMNcoMPLEMON <br /> Ground <br /> SPECT PE IT INFO. 5W <br /> grout <br /> Distance to sewer line <br /> ILI <br /> Domestic well on site. ® (y n <br /> If yes, location and distance ® y tf Iga <br /> 1 <br /> a •F.. <br /> �loet�d •r; � <br /> S,AMPL°Ihlts � <br /> Molding Temperature `fib e P <br /> ack <br /> ]Method <br /> Screening Method <br /> Tracking Sheet - (y n <br /> SPOILS <br /> b MATFPJALSIDE T OPMEI IT <br /> Storage Method <br /> Contamination Noted a (y n <br /> Storage Location �� � .� Casing type <br /> Blank ft. Screen � ft. <br /> Slat sire '01D <br /> C.ROUTING Lags cement <br /> Buckets bcntonite '�! <br /> P <br /> :Depth to rater _- <br /> L3a;s salad/gravel 5 <br /> Mix Ratios - �� Cailte� I�acic 1. VsNe I(> <br /> Installa6o Ibjletl�odP_ _ Suurgc Block: n (:Y I :l ) <br /> quantity 1nstal3ccl <br /> DiaCussed wit'lt geologist: - (Y/'11 ) <br /> arP hod� <br /> ll 9 <br /> 29 <br />