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WELL QA/QC FORM <br />Well Designation -0 <br />Date /Z - 8-- <br />Inspector 115-?Ile C/ <br />Page 4 of <br />3) Gravel Pack and Bentonite Seal. <br />a) Size of gravel used to backfill hole /ZI/C,4 <br />Reason size varied from that specified by Cotter geologist or <br />engineer <br />b) Depth to which gravel pack was placed <br />Does gravel pack extend to top of screen interval? <br />Yes i/ No Reason gravel pack does not extend to top <br />of screen interval <br />c) Size of bentonite pellets used for seal above gravel. pack <br />Depth to which pellets were placed 7,,?' <br />4) Cementation. <br />a) Emplacement of neat cement grout between well casing and <br />r borehole wall. <br />{ i) Volume of neat cement.grout emplaced <br />ii) Was grout emplaced with tremie pipe or .hose ;Vv. <br />Method of emplacement used other.than..:tremie pipe or <br />hose <br />iii) Was grouting operation continuous?,-Yes No.. <br />Reason for non-continuous emplacement <br />iv) Was there a return of grout to one half foot below the- <br />pitless adaptor or T-junction? Yes No <br />Reason for variation <br />b) Neat cement grout specifications. <br />i) Number of sacks of cement used .3 <br />ii) Number of gallons of water mixed with cement <br />iii) Calculated ratio of water to cement <br />iv) Was clean fresh water used? Yes 4/ No <br />Source of water _? <br />A-5