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Wes- ______..__.._ QA/QC Form <br />Well De ign tionhw-bv <br />• Date 10 2.1 ?jg <br />Inspector <br />P <br />as <br />Page 3 of 5 . <br />3) Sand Pack and Bentonite Seal <br />a. Size of sand used to backfill hole? 8- l2MEsN <br />5ACK5 Reason size varied from that specified by Cotter <br />.W1 (ct1 geologist or engineer: <br />b. Depth to which sand pack was placed?i4g11 Method <br />used to sound depth to top of sand pack: <br />5" ` MgRsccrc?? r c k lets Awc, -rA.PF m s7+Sur-_- <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? `14 " €s-I_L.E-rs <br />d. Depth to which bentonite was placed? 17- 5" <br />Method used to'sound depth of bentonite seal? <br />Trt t E tarps w t'r N 5' mpdAs up_eEz HPOK S AWP 'rAP6" ?l e- v/t?; <br />• f=lu v( az t4 ew-rAt,. <br />4) -GamentatIGn 6RoumA,[, <br />a. Volume of annular space between well casing and.hole wall <br />from top of bentonite seal to surface? <br />?lrY t 20 -.. <br />b. Emplacement of fte6t ce.,,ca grout between well casing and <br />borehole wall. <br />i ) Volume of neat cement grout emplaced? U. ?arGlows .fy1 ?x <br />Reason for variation between volume of annular space <br />and amount of grout emplaced: <br />7(D NvT FILL iq& rt L14Q SPAcs To -roP OF PVC, <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: