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QA/QC Form <br />Well Designation <br />Date 10123/95 <br />Inspector jeseN <br />.Page 3 of 5 <br />3) Sand Pack and Bentonite Seal <br />a. Size of sand used to backfill hole? (B- 12Me'--s1-/ <br />Reason size varied from that specified by Cotter <br />geologist or engineer: Cotor-4wo ZiucA S4-D <br />b. Depth to which sand pack was placed? 23? Method <br />Ft2sz SRCU F?L p used to sound depth to top of sand pack: Wes, -rAjag Me'Aav_ <br />?a goy z' <br />Does sand pack exte d 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? Y4" ?c?X!YoN?'ec3 PE' 's By p-L-P404 <br />14YUR.ATED PvE'uzotivu-_ a Tg t0c;4u,oNs <br />d. Depth to. which bentonite was placed? /7 q N = 17 - <br />Method used to sound depth of bentonite seal? <br />4) C-eRtt'nt l-Aid E?uv?2o,??cNTl+c. CTRAUn?+?G <br />a. Volume of annular-space between well.casing and hole-wall- <br />from top of bentonite seal. to surface? <br />SwP t'LC :b. Emplacement of neat cement grout between well.casing and <br />borehole wall. <br />_ x-ra t 6;14 t &I-7n i) Volume of neat cement grout emplaced?. <br />Co"' <br />So a.is Z,V_ Reason for variation between volume of annular space <br />and amount of grout emplaced: <br />Did N0 taSQ Use !OLCLRY CR_cL'4BLES4'8 A E?stOpim5 -35A ED °IRStNG SERA . <br />ii) Was grouting operation continuous? Yes <br />No Reason for non-continuous emplacement: <br />iii was there a return of grout to surface? Yes <br />No Reason for variation: <br />0-1