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Date: <br /> STT <br /> Premise Address: CONSRU— <br /> well No.: Total Depth <br /> Screen Length (from) <br /> Inspector: Filtet Pack (firom)�(to) <br /> Bentonite' (from) <br /> Permit No. Grout Drill' <br /> Drilling rig type �- (tO) <br /> Drilling Com Auger O.D. <br /> Comp I.D.Completion- StovP P /christie <br /> box (— c <br /> Drilled: <br /> le 012 <br /> Consultant _ casing <br /> height <br /> Geologist <br /> ABOVE-GROUND <br /> SPECIAL PERMIT INFO. CONFLEMON <br /> C}{A1S7Y-80X ' <br /> Distanceto sewer line GroundsurfacV O ON <br /> Domestic well on site - (y/n) ♦ — <br /> If yes, location and distance - grout <br /> ft. <br /> ft. _ ft. <br /> SAMPLING <br /> Holding Temperature <br /> Method soon = B <br /> Screening Method _ <br /> Tracking = C +tom pacts <br /> Sheet _ (y/n) <br /> SPOILS tt. <br /> tt. <br /> Storage Method <br /> Contamination Noted - (y/n) <br /> Storage Location MATE�ALS/DEVELOPMENT <br /> Casing type <br /> GROUTING Blank <br /> Slotsize—ft' Screen�_ft <br /> Depth to water Bags cement <br /> Mix Ratios Buckets bentonite <br /> Installation Method Bags sand gravel <br /> Quantity Installed Filter Pack type/size <br /> EH 29 29 Discussed with geologist: - (Y/n��— <br /> Type of method <br />