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(C N __. ,`mac 4)u- <br /> J60 �. <br /> 3125 g9s <br /> Date: ONS U O <br /> Premise Address: /�? ZJ� r` � l Total Depth �Q <br /> 5S64en mgt ( (to) <br /> Well No.: �✓' FB P (from)Lep _ o <br /> I (fro . <br /> Inspector. Gl}n �� ut (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Campl 'on - 411- <br /> Stone pipe/christie box (circle one) <br /> Drilling Company: S <br /> Driller. V-c C T caainq <br /> ight <br /> Consultant <br /> Geologist <br /> OUND -80X <br /> N <br /> SPECIAL PERMIT INFO- � ) Ground Surface <br /> -- <br /> Distance to sewer line ) <br /> Domestic well on site -M n) 00o r d(� fL <br /> If yes, location and die ce - <br /> R. <br /> OK <br /> SAAGUNC o sioctaa <br /> O c <br /> Holding Temperature O <br /> Method res s <br /> Screening Method <br /> Tracking <br /> SPOT yrs <br /> Storage Method <br /> V/�- MATEWAIS/DEVELOPMENT <br /> Contamination Noted - (y <br /> Storage Location g tYPe ffL <br /> B t, <br /> Slot <br /> GROUTING Bags cem <br /> Buckets benzo ' <br /> Depth to water ` Bags sand/ e1 <br /> Mix Ratios -1 Filter typesize <br /> Installation Method . ktem W-o Q S Block: - (Y/ n) <br /> Quantity Installed sed with geologist: - ( n ) <br /> Type of method <br /> EH 29 29 <br />