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Date:_ y'IS CONSTRUCTION <br /> Premise Address:'',, (( Total Depth <br /> 571 <br /> Well No.: Screen Length (from)' 0 (to) s0 <br /> Filtei Pack (from)_ �--39 (to)_ _ <br /> Inspector: Bentonite' (from)_ _(to) G� <br /> Grout (from) d (to) <br /> Permit No. Drilling rig type <br /> //�� Auger O.D. `� I.D. <br /> Drilling Company: C os aoc Completion- Stove pipe/chnstie box (circle one <br /> Driller: <br /> casing <br /> Consultant <br /> height <br /> Geologis - <br /> A OVE-GROUND <br /> C OMPL..mON CNAZ7Y-BOX <br /> SPECIAL PERMIT INFO COMPLETION <br /> Ground Surface <br /> Distance to sewer line grout+ <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - 3Z• (t. <br /> • ��. ft. <br /> 0 <br /> SAMPLING — c <br /> o <br /> 110ttad = c <br /> Holding Temperature mon <br /> Method <br /> 9,.,VIR-1 PaCR <br /> Screening Method = <br /> Tracking Sheet - (y/n) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location Casing type <br /> Blankft. Screen_ /� ft. <br /> GROUTING Slot size 0.OZv <br /> Bags cement <br /> Depth to water Buckets bentonite_Y <br /> Mix Ratios Bags sand/gravel <br /> InstallationMethod Filter Pack type/size <br /> ... ._... _ -------._-_ S.urge_Block:_(.y_/n_) <br /> Quantity Installed_ <br /> Discussed with geologist: - (y/ n) <br /> EH 29 29 Type of method <br />