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s <br />w QA/QC Form <br />Well Designation lgtj-5R <br />Date 1 a 30 <br />Inspector iese? <br />Page3 of 5 <br />3) Sand Pack and Bentonite Seal <br />a. Size of sand used to backfill hole? e -lZ HFsO- <br />Reason size varied.from that specified by Cotter <br />geologist or engineer: CnLoeAa=?-SiL,eA Sa?o <br />b. Depth to which sand pack was placed? -- 6Method <br />105ACK5 used to sound depth to top of sand pack: TfZEMiE P,pE' <br />wcTH S TAPE MARKS- <br />Does sand pack extend 2 feet above top of screen <br />interval? Yes - No Reason sand pack does not <br />extend 2 feet above top of screen interval: <br />C. Size of bentonite chips or pellets used for seal above <br />sand pack? SpnowrrF P6-cL4?rs ay PEI. -pjuy <br />HYDRA:r" H 5 t?Ns WA-(E-R- <br />d. Depth to which bentonite was placed? -4' <br />Z r'3ue?c?TS <br />O-,bOprwrm N-Lays Method used to sound depth of bentonite seal? <br />Tp-e-ktr Rpm w" S1 TAPs nh&rs A-ov --tA E ME'A5tA9Z. <br />4) Gementat±rrn <br />a. Volume of annular space between well casing and.hole wall, <br />from top of bentonite seal to surface? <br />l,•p 1 r???r3 !'1•?0??11s <br />b. Emplacement of neat cemeft grout between .weal casing and <br />-p Nor ??? 2owT borehole wall. <br />i) Volume of neat ce en <br /><<c- TtA- flN?"``?? ?P Reason for vari ion <br />Uls? 'b=T??e?+j?-rE eGe cars . and amount of. rout <br />wti? w 2E kf"Yp2A-rc+2 <br />lls c o l b we.?ue..?- f' ¢.l l??s ?I?o <br />qi k r ?MU,?.v? a-nhutar S fazce <br />O,,roun&w-W. w+c _ ??) Was <br />No- <br />t grout emplaced7 <br />between. volume o <br />emplaced: <br />ting operation con nuous? Yes <br />Reason for non-c tinuous emnl <br />bc-tow Pv e c.A5 .A5 iii Was there a ret <br />No Reason <br />of grout to <br />variation: <br />i <br />ar <br />? Yes