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�aAoNITomo wmL ngnAhLAnoN REP64 <br /> Date: •2�` 12— CONSTRUCTION <br /> � p 15' <br /> Premise Address: W_ 1325 ¢.bo'� ...� Total Depth <br /> Screen <br /> Pack (from) W (ta) <br /> Well No.: W FilterBentonite <br /> Grout (from)_ <br /> Inspector: •- <br /> d Z ��L� Dn'llu�g rig type <br /> Permit No. -L _ .... Auger O.D. I.D. <br /> J Completion-Stove pipe/chrisde box (circle one) <br /> Drilling Company: <br /> Driller:_ 10�C.I.J&ruvA f92j%t- T caeinq <br /> S sue.-6-v_A MA1 Vc�r ltc rte- height <br /> Consultant—}� • � <br /> Geologist <br /> .�VZ" cG�5 =Wet r <br /> AI;VOV 7.3— <br /> oum CHPlM43OX <br /> COWMION COMPLEX! <br /> SPEC[AL PEitMIT INFO. <br /> Distance to sewer <br /> Domestic <br /> Domestic well on site- (Y <br /> If yes,location and distance - & <br /> y� <br /> �r <br /> SAMPLING <br /> Holding Temperature <br /> Method I <br /> Screening MedtodI ; <br /> Tracking Sheet - (y/n) <br /> ,r <br /> Storege Method MA�RIALS(DEV'E-I.OPMENT <br /> Contamination Noted- n it <br /> Storage Location„-,%oza - Casing type 2• G <br /> Blank t3. S ` ft. Screen & <br /> Slot size . 0 2 to <br /> Bap cement <br /> Buckets bentonite <br /> Depth to water Sags sand/gravel 3 bG <br /> Mix Ration Fitter Pack type/ ize.... -- <br /> Installation Method Surge Block: - ( n) <br /> Quantity Installed Discussed with geologist: - y n) <br /> Type of method_ Z"kl�-._ <br /> EH 29 29 <br /> gF <br /> ■ <br />