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Date: l� CONSTRUCTION <br /> Premise Address:jAe -)46 4rpt✓I- <br /> l' Total Depth <br /> Well No.:_ MIA) '2 Screen Length (from) (to) S-0 - <br /> Filtei Pack (from) 4 (to) ba <br /> Inspector: Bentonite' (from) (to) ' <br /> (S(from) 0 (to) <br /> Permit No. Drilling rig type_ &, <br /> //11 Auger O.D.��� I.D. <br /> Drilling Company: ( / sinal-Q Completion - Stove pipe/clinstie box (circle on <br /> Driller: <br /> casing <br /> Consultan height <br /> 7771 <br /> Geologist <br /> ABOVE-GROUND <br /> CO W L.ETIO N CNA LM-30X <br /> SPECIAL PERMIT INFO. COMPLETION <br /> Ground Surface <br /> Distance to sewer line <br /> Domestic well on site - grout(y/n) c3 <br /> If yes, location and distance <br /> m <br /> SAMPLING -- <br /> Slatted - —' c <br /> Holding Temperature &4i�c'on <br /> Method wrivs?lack <br /> Screening Method = <br /> Tracking Sheet - (y/n) <br /> SPOILS <br /> ft. <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) - <br /> Storage Location Casing type �h <br /> Blank__ �o ft. Screen to ft <br /> GROUTING Slot size_ <br /> Bags cement <br /> Depth to water Buckets bentonite Z.S <br /> Mix Ratio§ Bags sand/gravel <br /> Installation Method Filter Pack type/size <br /> __...-- . _Quantity n-)--- <br /> Installed Discussed with geologist: - (y/ n) <br /> EH 29 29 Type of method <br />