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a <br /> 130ULOS ENVIRONMENTAL, INC SAMPLING INFORMATION SHEET <br /> ient <br /> ClSampling Date <br /> Site Project No <br /> ; � LD <br /> a Well Designation vU — <br /> i , <br /> Is serup of traffic control devices required'? YES time hours <br /> Is there standing water in the well box9YES Above TOC Below TOC <br /> Is top of casing cur lever 10�) <br /> If no, see remarks <br /> is +veli cap sealed and locked? / NO If no, see remarks <br /> Htighi of well casing riser (in inches) It;, <br /> well cover Type 8" or 12"UV 12"EMCO 8"or 12" BK 8" Christy <br /> 12 Christy 8" M&D7y- 12"M&D 12"DWP <br /> 12 CNl 36"CNI 12"Porneco Other <br /> General condition of wellhead assembly Excellent Good--� � Fair Poor <br /> Purging Equipment 2" disposable bailer — _ Submersible pump <br /> 2" PVC bailer Dedicated bailer <br /> 4" PVC bailer Centrifugal pump <br /> Sampled with Disposable bailer - ,,f"P Teflon bailer Disposable Tubing <br /> Well Diameter 2" 4" 6" 811 <br /> j Purge Vol Multiplier 0 16 065 1 47 2 61 gal/ft <br /> t Inmal Measurement Recharge Measurement <br /> ' Time Time 10 ' a Calculated purge � <br /> Depth of well o Z G Depth to water 7 Actual purge <br /> Depth to water _ rjt�- <br /> Stan purge 0 ' Sampling time © = <br /> Time Temperature E C I PH Turbidtt Volume <br /> Sample appearance _ C,— _ Lock \ _ <br /> Equipment replaced (check all that apply) Note conattion of replaced item(s) <br /> 2" Locking Cap Lock 7/32 Allenhead <br /> 4" Locking Cap Lock-Dolphin 9/16 Bolt <br /> 6" Locking Cap Pinned Allenhead (DWP) <br /> *Remarks <br /> Signature <br />