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DOULOS ENVIRONMENTAL COMPANY INFORMATION SiEET <br /> Client: Sampling Date: `3 _d <br /> Site • _ _ _ - ,�� Project No. <br /> CZ4,% ate.. Well Designation: <br /> I <br /> Is setup of traffic control devices required? YES time : hours <br /> Is there standing water in well box? 9 YES Above TOC Below TOC <br /> Is top of casing cut level? NO qMD If no, see remarks <br /> Is well cap sealed and locked? No Yn If no, see remarks <br /> Height of well casing riser (in inches) : 1), <br /> Well cover type: 8'" W 12" W 12" EMCO 8" BK <br /> 12" BK 12" DWP 12" CNI 36" CNI her <br /> General condition of wellhead assembly: Excellent oo 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: Teflon bailer: <br /> - <br /> Well Diameter: 2" 4"_L 6" 8" <br /> Purge Vol . Multiplier: 0. 16 0. 65 1 . 47 2 . 61 gal/ft <br /> Initial Measurement Recharge Measurement <br /> Time: 1t.� Time: L,r[1(� Calculated purge : <br /> Depth of well : Depth to water: 4 Actual purge. a!�, !: <br /> Depth to water: lq,6 Z <br /> Start purge: /7E$ sampling time: /�_r <br /> Time Temp. E.C. pH Turbidity volume <br /> 1?03 73, 1 - 73 1 <br /> Sample appearance: Lock: <br /> Equipment replaced: (Check all that apply) Note condition of replaced item <br /> 2" Locking Cap: Lock #3753 : 7/32 Allenhead: , <br /> 4" Locking Cap: Lock--Dolphin: 9/16 Bolt <br /> 6" Locking Cap: Pinned Allenhead (DWP) : <br /> Remarks : <br /> Signature: <br />