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DOULOS ENVIRONMENTAL, INC. SAMPLING INFORMATION SHEET <br />.r <br /> Client Sampling Date <br /> 3 • Site � -9 /e� So<<q��s_ Project No <br /> Well Designation w <br /> 3` <br />�s <br /> s Is setup of traffic control devices required9 YES time hours <br /> = Is there standing water in the well boxy YES Above TOC Below TOC <br /> Is top of casing cut level? NO If no,see remarks <br />,i Is well cap sealed and locked9 NO If no,see remarks <br /> Height of well casing riser(ui inches) <br /> Well cover type 8"or 12"UV 12"EMCO le— 8"or 12"BK 8"Christy <br /> 12" Christy8"M&D 12"M&D 12"DWP <br /> 12" CNI 36" CNI 12"Pomeco 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. A Teflon bailer Disposable Tubing <br /> f <br />� Well Diameter 2"�� 4" 6" 8" <br /> x Purge Vol Multiplier 016 065 147 2 61 gal/ft <br /> Initial Measurement Rechar e Measurement <br /> Time —7 ' 20• O Time � % 3 � Calculated purge Depth of well 6 Depth to water y • �10 Actual purge <br /> Depth to water <br /> Start purge Sampling time 7 6`1 <br /> ti <br /> Time Temperature E pH Turbidity Volume <br /> 'Irloop' 7 -�6 r <br /> Sample appearance Lock <br /> Equipment replaced (check all that applyl Note condition of replaced item(s) y <br /> 2" Locking Cap LocK "'.'7Jj2 Allenhead <br /> 4"Locking Cap Lock-Dolphin '4 9/16 Bolt <br /> 6" Locking Cap Pinned Allenhead (DWP) <br /> ORernarks <br /> s <br /> Signature <br />