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NOUITORZM M6LL XWgrAyXA'ZrC N REpoi, <br /> Date <br /> SON <br /> Premise Address: �✓ rj� <br /> Inspector: Well No. 4V <br /> Total Depth v <br /> Screen Length fQ <br /> ' Filter Pack 6p <br /> a Permit No. fc) -- 6 sentonite pellets <br /> Consultant 4 Grout <br /> Geologist C .. C Complettion-Stove pi is box <br /> Auger O.D. jN�" <br /> 4 Auger I.D. <br /> Holding Temperature, Ute <br /> Method f ----`"--� <br /> 3 a✓1 <br /> Screening Method <br /> Tracking Shoot (y� IIBOYE{3ApxaD <br /> COMPLErIGN C►lRISTf4)OX <br /> M Orowd Surfaw 1QN <br /> Storage Method S - VWA <br /> ContamLA&tion Noted - yes/no <br /> Storage ationg IL <br /> .r 4 11. <br /> P _ • <br /> Distance to sewer line`:5U mrd 7 <br /> Domestic Well on site b"I" <br /> If yes, location a distance - = <br /> gmvw pm* <br /> ..�A. ft. <br /> Rlus SSD: <br /> Depth to water_ Casin Ype <br /> Mix Ratios 9 t <br /> Installation Method t� Blank-_--T ft. Screen-.G-ft. <br /> Quantity Installed Slot size © Z. <br /> Rage Cement <br /> a Buckets bentonite <br /> 4 Sr Cori q C/Vjr�/ Sage sand/gravel <br /> Filter Pack type/size <br />