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ENVIRONMENTAL RESOURCES MJSGEMENT i <br /> ERM—WEST <br /> ACHRISTY BOX <br /> FIELD WELL COMPLETION FORM <br /> Job � �� r ! ❑ LOCKING STEEL COVER <br /> • Namd 5TdC_ fc-, Owner Un 4" I4Ci*l`t< l�r c.Ilk INCH DIAMETER <br /> Location.JAO C[� &21 25T 7 .2 STEEL CONDUCTOR <br /> CASING <br /> Logged Revie Project } I to feat <br /> BY D'✓ k By EM Munger v0kyl D 450S_T!stp <br /> � INCH DIAMETER <br /> well �, ) �� BOREHOLE <br /> Number `�t�ly�� DrAler toyQ,feat <br /> Date Of Installation / Hours Drilled <br /> NITE�EMENT <br /> E4mpmcnt "ENT' <br /> EAL OR <br /> F' Inch Hollow Stem Auger Inch Rotary Wash SEiA L K CEMENTsANa <br /> Gallons of Water 0'S to teat <br /> Used During Drilling: Gallons <br /> Method of Decoutaminatcon , �� TOP OF CASING AT <br /> Prior to Drilling ✓ G4 <br /> �f �r 0�SFf?ET ABOVE/ATI <br /> Well Permit to- { �� yL� Issuing Agenclr�4►S �ad9lit r'1 4.O_ kh4Y_ GROUND LEV> L <br /> DEVELOPMENT P 2-5-INCH <br /> �NCH DfAMETER <br /> BOREHOLE <br /> Method of to S© feet <br /> Development n <br /> p� INCH DIAMETER <br /> Development SCHEDULE 40 PVC <br /> Began Datm Time: BLANK CASTING <br /> Depth to Water 0-Z'5- to ySfee t <br /> Before Development Feet <br /> BENTONITE-CEMENT <br /> Yield. Time. Date EAL OR <br /> CPM Fr m. To I , SSACK CEMENT-SAND <br /> Yield. Tune: Date. SEAL ) <br /> GPM From. To Q� to 31 <br /> lent <br /> Total water Removed BENTONITE PELLET <br /> During Development Crallons . SEAL <br /> Description <br /> ta of ZZ / o l <br /> 2,2 <br /> Turbidity <br /> feet/` <br /> at End Gear © Slightly cloudy <br /> of Development Q Mod.Turbid L"1 Very Muddy <br /> Odor of WaterSAND PACK <br /> _ 3Z' <br /> to tact <br /> Water C] GroundSurf= QTank Truck � TER <br /> AAIE <br /> Discharged (� Storm Sewers QINCH Di <br /> Storage Tank <br /> Ta Q Drums Q Other SLOTTED ( DI 01010 <br /> ���//nc n) S CRUUEgQE�NNr <br /> Depth to Water Date/Time 3` 's to feet <br /> After Development Fest Well Development Complete. n <br /> pC <br /> Well Elevsuoa as <br /> Feet Measuring Point(i a lop of Casing) INCH DIAMETER SCH EDULE 40 PVC <br /> MATERIALS USED 1/1':L to <br /> SILT TRAP <br /> 1 's to s0 feat <br /> Sacks of Sand <br /> Sacks ofBOTTOM WELL CAP <br /> Cement Q <br /> feat <br /> Gallons of Grout Used <br /> HO L E CLEANED OUT TO <br /> Sacks of Powdered Bentonite feat <br /> Pounds of Heutotate Pellets if BOTTOM OF BOREHOLE <br /> Feet of Inch PVC Blank Casing . ^�It <br /> Feet of Inch PVC Slotted Screen NOT TO SCALE <br /> Feet of Inch Steel Conductor Casing <br /> ADDITIONAL INFORMATION- <br /> Yards Cement-Sand(Redt-Mui)Ordered <br /> Yards Cement-Sand(Reda-Mu)Used <br /> Concrete Pumper Used? Na Yes <br /> Name <br /> Well Cover Used- Locking Steel Cover <br /> Diversified Well Products Box <br /> Christy Box <br /> Other <br /> I <br />