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ENVIRONMENTAL RESOURCES NAGEMENT <br /> ERM-WEST j <br /> FIELD WELL COMPLETDOK FORM I I CHRISTY BOX <br /> Job l <br /> ❑ LOCKING STEEL COVER i <br /> Name: S�uG Owner, t " <br /> L4CSdom S c 8�,�� --�-,INCH OIAMETER <br /> Joh STEEL CON OUCTOR <br /> y`! CASING <br /> Logged I, ) ;riawed <br /> Jar �✓�'{ LI"L � � STrho `i pp to lett <br /> wen /�/� D-5,INCH DIAMETER <br /> Number o C, Driller. � I• BOREHOLE <br /> Date of Installation: O / to ftrrt <br /> Hours Drilled i <br /> Equipment Q - i BENTONITE-CEMENT <br /> v` �luck Hollow Stem Auger Inch Rotary Wish SEAL OR <br /> ACK CEMENT-SAND <br /> SE <br /> Gallons of Water O�� 3s� <br /> Used During Drilling; Gallons ..to -irKt <br /> Method of Decontamination 5i <br /> Prior to Drilling; v Q�� Cloth � I TOP OF CASING AT <br /> FEET ABOVElATJ <br /> rm <br /> well Peit». Issuing Agency. foes eI e h �pGtttiTy ! GROUND LEVEL <br /> DEVELOPMENT <br /> OPMENT <br /> p d•)5 <br /> INCH DIAMETER <br /> Method of i BOREHOLE <br /> Development: ! 0 To So 'feet <br /> i <br /> Development Il INCH DIAMETER <br /> Began Date Time SCHEDULE 40 PVC <br /> Depth to Water i BLANK CASING <br /> Before Deveiopmene Feet � ii 0112--5- finet <br /> Yield: Time: part BENTONITE-CEMENT <br /> SEAL OR <br /> CPM rom TO <br /> Yttld BSACK CEMENT-SAND <br /> Time <br /> Dacc <br /> OPw[ From SEAL <br /> To O,� -7z <br /> 1 to--- feet � <br /> Tont Water removed <br /> During Developmene Crallaas BENTONITE PELLET <br /> �• <br /> SEAL <br /> Description of I 3.2— to 'Meet <br /> Turbidity at Ead Q Clear Slightly cloudy <br /> of Development: Mod.Turbid Q Very Muddy <br /> I ��rt wurwwn k <br /> Odor of water j 3 .AN PACK r <br /> Water <br /> Ground Surf= Tank Track <br /> Dischargied <br /> n <br /> O� <br /> Tx © Storm Sewers Storage Tank INCH DIAMETER <br /> Drums <br /> Q Otho I SLOTTED { O.0.10 r <br /> " Depth to water inch) SCREENDam/rime3 j <br /> After Development Feet well Development Complete• I ;!! '?7'Zto-12:5-- <br /> feet <br /> Well Elevation Feet._......Measuring Point(Le.Top of Cuing} INCH DIAMETER ) <br /> ( SCHEDULE sO PVC <br /> MATERIALS USED LANK SILT TRAP ! <br /> Sacks of <br /> Sand I r�to !wt <br /> Sacks of Cement BOTTOM WELL CAP <br /> Gallons of Grout Used l I —50 <br /> — —feR <br /> _Sacks of Powdered BearoHOLE CLEANED OUT TOnite I " I� <br /> • � T te,et <br /> _,---- 4 Pounds of Bentonite Pellets <br /> BOTTOM OF BOREHOLE <br /> Feet of Inch PYC Blank Cuing P <br /> Feet of Inch PVC Slotted Screen it <br /> NO TO SCALE <br /> Feet of Inch Steel Condncwr Casing <br /> � <br /> Yards Cement-Sand(Keds-Mi:)Ordered ADDIT!OVAL INFI7RMATION:Ia <br /> Yards Cement-Sand(Redi-Mix)Used <br /> Caacmte Pumper Used? No <br /> None <br /> Well Cover Used: Locking Steel Cover <br /> Diversified well Products Box <br /> -- Y Christy Box 11 !![ <br /> Other ti <br /> f i- <br />