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llluT ORINC vv> ►Ttol�t 1 <br /> Date: ll y I CONSTRUCTION <br /> Premise Address: -7 7 7 7 �/ �` t' <br /> Total Depth__ <br /> Well No.: �'� 1�1/` � Screen Lenges ( �.....-�_ � <br /> Filter PWk (from) (to) ' <br /> Inspector: c(_-� _ tanite Grout (from)(from �� () <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. r' <br /> r ` Completion- Stove pipe/christie box (circle one) <br /> . Drilling Company:_ ,�.{� <br /> Driller• C-LlQ casing <br /> _ height <br /> Consultant <br /> Geologist -14X� <br /> Ate-GROUND <br /> ooWtETtoN lox <br /> cTI <br /> SPECIAL PERMIT INFO. Gmurd Sunoco <br /> Distance to sewer lineD 4 a <br /> Domestic well on site eYce <br /> If yes,location and di8 <br /> It. _ <br /> •AK <br /> 'a A <br /> SAMPLING air <br /> slattedtr W /w <br /> % <br /> Holding Temperature <br /> Method ._ Oniwl pads <br /> r� <br /> Screening Method Y')D <br /> i Tracking Sheet - n ) _ <br /> L2 <br /> SPOW <br /> Storage Method - MATERIALS/DEVELOPMENT <br /> Contamination Noted - (,yY n <br /> Storage Location GAJ'` 8,1, i.&AuP-t,7 Casing type <br /> Bunk t rl ft ScrVett�. ft <br /> Slot size { Do - <br /> GROU NG Bags cement <br /> Bucket:bentonite 2 r <br /> Depth to water _ Bags sand/gravel - <br /> Mix Ratios - Filter Pack type/size- <br /> Installation Method Surge Block: - ((y-)/ n ) <br /> Quantity Installed Discussed with geologist: - y n <br /> a Type of method -A <br /> EH 29 29 ,�� <br />