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s <br />WELL QA/QC FORM <br />Well Designation Rro e <br />Date 12 -e-o <br />Inspector 7 ,e <br />Page 6 of 6 <br />3) Was a check valve placed between pump and pump column? <br />Yes No If not, reason for not installing check valve <br />4) Was pump column (pump discharge line) connected to header pipe <br />line? Yes No if not, what provisions were made to <br />dispose of water produced by well? <br />IV. Review of any variation from the construction specification by Drilling <br />QA Coordinator and Drilling QA Inspector. <br />Location of <br />Drilling QA Coordinator Drilling QA Inspector Additional. <br />Signature Date Signature Date Documentation <br /> <br />1 <br />A-7