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Y <br /> AN=Zr4H0XMfflffA1,1NM SAMPLING INFORMATION SHEET <br /> Client: AJ -0 <br /> Project No: Z- <br /> Site:_C166 5 difligQW0Z 51 Well Designation: r,^, L <br /> 0 d..a 64- <br /> Is setup of traffic control devices required? YES Setup& Takedown time: hours <br /> Is there standing water in well box? YES (Above TQC Below TOC} <br /> Is Top of Casing cut level? - NO (If NO please explain in remarlks) <br /> Is well cap sealed and locked? NO ( If NO please explain in remarks) <br /> Height of Well Casing Rlser I in inches) <br /> General condition of Wellhead assembly - Fakcaflentoodi Fair Poor Il xplain in ramarksl <br /> Purging Equipment: X 2" Disposable bailer Submersible pump <br /> 2' PVC bailer Dedicated bailer <br /> 4" PVC bailer <br /> Sampled with: Disposal bailer: Teflon Bailer: <br /> Well Diameter: 2" )C 3" 4" _ 6" 8" <br /> Purge Vol. Multiplier: 0.163 0 367 0 653 147 2.61 gal/ft <br /> 22-- � <br /> I O " iecharae Measurement <br /> rime: 06 c7 _ Time: Calculated purge: i <br />;Depth of well: Depth to water: Actual purge: <br /> Depth to water: d 7 p q� <br /> Meter Calibration Temp E.C. pH Turbidity <br /> Initial reading <br /> I e Adjuz3ted ramming { <br /> Start purge. 69: 3 U Sampling time: 1 30, / Sampling Date: !a 1 <br /> Mme Temp. E.C. <br /> '/] /gyp!HrJ[� Turbidity Volume <br /> l <br /> 1 <br /> Sample appearance: c t- c%IL <br /> QC samples collected at this well: Lock: rva <br /> Equipment replaced: (Check all that apply) Note condition of replaced stem. <br /> 2" Locking Cap: C Lock #2357• = Lock #0909: 0 <br /> 4" Locking Cap: Lock #3753: n Lock-Dolphin: �J <br /> Remarks: L aur &Gc H A 1Z&0 <br /> . GUf}TEI•L = C��. <br /> Signature Review <br />