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WELL QA/QC FORM <br />Well Designation <br />Date <br />Inspector T. ?.?17 <br />Page 3 of 3-T <br />D. Well casing and screen: <br />I) Well casing and screen specifications. <br />a) Type of wel l casing and screen used Pf?G?ir?? wl??:? <br />Reason other than PVC casing and screen with screw joints <br />was used <br />b) Nominal diameter of casing and screen used Reason for variation from 4 inch nominal diameter <br />2) Installation. <br />a) Length of screen installed .S <br />Screened interval: From Iz..0 To 7.0 <br />Screen slot size 0,0,3" <br />Reason for variation from specified screen interval and.s.lot <br />size <br />c . <br />b) Length. of sediment trap installed.below screen on withdrawal <br />wel Is <br />Reason for.'variation from specified 5, foot interval <br />a'0 <br />c) Total length of 'casing installed? 13,0' . <br />Number of joints used <br />Was sufficient casing installed to reach from total depth of. <br />hole to one foot above ground surface? Yes No <br />Reason for variation <br />d) Was a pitless adaptor installed on the casing of withdrawal <br />wells or a T-junction on the ca ing of injection wells below, <br />the frost line? Yes No Depth at which pitless.. <br />adaptor or T-junction was installed <br />?- -0 <br />A-4