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ENVIRONMENTAL RESOURCES MOGEMENT <br /> ERM—WEST <br /> FIELD WELL COMPLETION FORM )eCHRISTY BOX <br /> /� -r j7 / �] ❑ LOCKING STEEL COVER <br /> Name. `^ /ZC L�C Owneryl`4tib'1 (r+CAk_ t-[c c( "c'44 <br /> f 97,24E <br /> - ICO DIAMETER <br /> STELoeauaa CASING CONAUCTOR <br /> lob w CASING <br /> Logged Renewed Project T`J T i to feet <br /> Hr Hy� �/� Mxnagcr kl .3/ rpt o <br /> Well /� /, l �) /f J NCH DIAMETER <br /> Number ' `w K �� L.� t-i 5BOREHOLEDriller <br /> [} -2 to O fret <br /> Date of Installation. r Hours Drilled <br /> BENTONITE-CEMENT <br /> EquipmentSEAL OR <br /> U`jz Inch Hollow Stem ra <br /> Auger Inch Rory Wash B.SACK CEMENT-SAND <br /> SEAL <br /> Gallons of Water to IL}4ma, <br /> Used During Drilling; Galloon <br /> Method of Decontamination TOP OF CASING AT <br /> Pnor to Drilling <br /> O•.ZSFEET ABpVEIATJ <br /> Weil Permit rr O/SGZ(0 Issuing ABeacy ld ti .JidGyffr•j1I s%uK��f GROUND LEVEL <br /> DEVELOPMENT 9�SINCH 01AMETEPI <br /> BOREHOLE <br /> Metitod <br /> of <br /> Developmear 11.22—feet <br /> tveto <br /> Development INCH DIAMETER <br /> SCHEDULE 40 PVC <br /> Began Nate Time BLANK CASING <br /> Depth to Water o'25—to _?'(115 feet <br /> Before Development: Feet <br /> BENTONITE-CEMENT <br /> Yield Time. Dates SEAL OR <br /> GPM From. To I I 8-SACK CEMENT SAND <br /> Yield Times Date <br /> GPM From. To <br /> '�to3f�L fres <br /> Total Water Removed BENTONITE PELLET <br /> During Development Galeas . SEAL <br /> Description of Z I <br /> Turbidity at End ©Clear 0 Slightly cloudy �yl.� to frR <br /> of Development: Q Mod Turbid Q Very Muddy — ( <br /> J.-"KSA <br /> F4��i• <br /> Odor of Water <br /> 3.5D PACK <br /> tofact <br /> Water Q Ground Surface Q Tank Truck <br /> Discharged 0 Storm Sewers =Storage Taak _102— INCH DIAMETER <br /> TO: =Drums = Other SLOTTED ( g2-0(0 <br /> int:hl CREEK <br /> Depth to Water Datemme 3q..5- <br /> } <br /> After Development Feet Weil Development Complete _ to ret <br /> Well Elevauon Feet Measurtag Point([a Tap of Casings _, INCH DIAMETER <br /> SCHEDULE 40 PVC <br /> MATERIALS USED (j8gL�ANNK SILT TRAP <br /> Sacks of Sand <br /> /L......to .5 D tart <br /> Sacks ofBOTTOM WELL CAP <br /> Cement 0 fret <br /> Gallons of Grout Used <br /> WOLE CLEANED OUT TO <br /> Sacks of Powdered Bentonite feet <br /> Pounds of Searaatte Pellets B¢ITGM OF BOREHOLE <br /> Feet of Inch PVC Blank Casing -5 O fmm <br /> Feet of Inch PVC Slatted Screen <br /> NOT TO SCALE <br /> Feet of Inch Steel Coodactor Casing <br /> Yards Cement-Sand(Redi-Mix)Ordered ADDITIONAL INFORMATION: <br /> Yard's Cement-Sand(Reda-Mrz)Used <br /> W.0crete Pumper Used? No Yes <br /> Name <br /> Well Cover Used Locking Steel Cover <br /> Divennfied Well Products Hoz <br /> Christy Boz <br /> Other <br /> _ SC <br />