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ENVIRONMENTAL RESOURCES NAGEMENT � <br /> ERM-WEST <br /> FML')WELL COMPLETION FORM / CHAISTY SOX <br /> Nob / L' /�� �, • `7 E3 LOCKJNY STEEL COVES; <br /> Name:U P 7T0 Gk Owner. {/!tti 4G t G c �wr� 1 <br /> Location: DIAMETER <br /> Location: 5 job,, 8 STEEL CONDUCTOR ° <br /> CASING <br /> Logged L",t�} Reviewed Pro' J <br /> By 1���1 SY <br /> Weli r°� INCH DIAMETER <br /> Number, Al C�1 I7rillar- r'CO � f`t BOREHOLE <br /> Gate of Installation a ` `l t ��to.._6 feet <br /> Hours Drilled: 13 <br /> EQuipmeat: <br /> 13ENTONITE-CEMENT <br /> QQ � <br /> ISEAL, OR � <br /> 11--h Hallow Stem Auger Inab Rotary Wash I BSACK CEMENTSANO <br /> ` <br /> Gallons of Water SEAL <br /> i� ,r <br /> Used During brilrialp _.. Gaponrr I �•S to ILfe" <br /> Method of Decontamination j f <br /> Prior to Drilling_ / TOP OF CASING AT <br /> WeIl Permit U�S�Z(� !{ 10 25-FEET ABOVEIATI <br /> Issuing Agency. /d T K J G4 u t 6/OLLrldi <br /> MNTp caouND LEVEL <br /> DEV EL—�P �] F,2�NCH DIAMETER <br /> Method-- f BOREHOLE <br /> } <br /> Development: i & tom=�feet ' <br /> Development <br /> } INCH DIAMETER <br /> Degan Date: Time: f BLANK CAS 0PVC <br /> Depth to Water "� '� O•zstc »• feet <br /> Before Development Feet <br /> Yield. SENtONITE-CEMENT <br /> From: SEAL OR r( <br /> •PA{ rn To SEAACK CEMENT-SAND <br /> Yield: Time: Date <br /> GP.m From To <br /> ,7 t0—�..t��}ett <br /> Tatal Water Removed <br /> During Development Gallons BENTONITE PELLET <br /> SEAL 7 <br /> Description of L�j,Lto >3 tett <br /> Turbidity at End []Clear [] Slightly cloudy K to <br /> of Development © Mod.Turbid Q Very Maddy 4 <br /> 4 N.rs «ur•e.r <br /> Odor of Water. AY PACK <br /> Water Q Ground SurfaceTank Truck <br /> t O }ee t <br /> Discharged Q <br /> Tx ©StormSeaen DStorage Tank �� � � INCH DIAMETER <br /> Q Drums <br /> Q Other S LOTTED ( <br />� Depth to Water <br /> inert) C}REEN <br /> Date/Time <br /> After Development Feet Well Development Complete: I 3 ` [O�t=.feet <br /> Well Elevation:— Feet..._....Measuring Point(i.e.Top of Casing): -wit— INCH DIAMETER <br /> SCHEDULE 40 PVC <br /> MATERIALS8L,A�N'K SILT TRAP <br /> Sand <br /> larks of A to 5-0 feet ` <br /> ,p <br /> Sacks of <br /> Cement BOTTOM WELL.CAP r <br /> � f ' <br /> ;Q feet '3 <br /> Gallons of Groat Used i <br /> HOLE CLEANED OUT TO <br /> Sacks of Powdered Bearogitelit <br /> h. <br /> r feet <br /> Pounds of Bentonite Pellets STTOM OF BOREHOLE <br /> Feet of Inch PVC Bbuik Casing feet <br /> Feer of ' <br /> Inch PVC Slotted Screen <br /> 11 NOT TO SCALE <br /> Feet of Inch Steel Conductor Casing <br /> Yards Cement-Sand(Recti-Mix)Ordered <br /> t AD�DITI OVAL INFORMATION: <br /> _Yards Cement-Sand(Redi-Mia)Used <br /> I <br /> Concrete Pumper Used? No <br /> Yes <br /> Name Il i <br /> Well Cover Used: Locking Steel Cover <br /> Diversified Well Products Sox <br /> Christy Sox <br /> Other <br /> K .. f <br />