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Date: <br /> CONSTRUCTION <br /> Premise Address: d <br /> Total Depth <br /> Well No.: Screen Length (from)__ (to) ?{ <br /> Filter Pack (from) (to)(-Z� <br /> Inspector: Bentonite (from)_ it (to)—/LI�t- <br /> Grout (from) C> <br /> Permit No. Drilling rig typef'� <br /> l Auger O.D._ 8� " I.D. <br /> Drilling Company: 1 ' SC'�ioilc Completion - Stove pipe/chnstie box (circle one <br /> Driller: <br /> T casing <br /> Consultant 377 height <br /> Geologis QMLtp �sr��` <br /> A O VE-G R C(lND <br /> CO W LEi•)O N CHR 1 M-8Cx <br /> SPECIAL PERMIT INFO. COMPLETION <br /> Ground Surface <br /> Distance to sewer line <br /> Domestic well on site - (y/n) flrccrt <br /> If yes, location and distance - /�Z• Ft. <br /> m <br /> SAMPLING <br /> slotted _ — c <br /> Holding Temperature &- con <br /> Method - 72vs;Pack <br /> Screening Method = <br /> Tracking Sheet - (y/n) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location Casin g type_ U <br /> Blank _ft. Screen /J ft. <br /> GROUTING Slot size 0.020 <br /> Bags cement <br /> Depth to water Buckets bentonite 2 <br /> Mix Ratios Bags sand/gravel <br /> Installation Method Filter Pack type/size <br /> Block:-=(-Y-/_n_)_ <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> EH 29 29 Type of method <br />