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w' DOULOS ENVIRONMENTAL COMPANY SAMPLE%i � INFORMATION SHEET <br /> Client: .' - Sampling Date. ��-^_-��`�-o C <br /> situ axeo, /3 Project No <br /> M 79 Well Designat Lon: <br /> J - <br /> i <br /> Is setup of traffic control devices required? YES time: T hours <br /> Is there standing water in well box? Cgp Y Above TOC Below TOC <br /> Is top of casing cut level? NO if no, see remarks <br /> Is well cap sealed and locked? NO S+ If no, see remarks <br /> Height of well casing riser (in inches) : <br /> Well Cover type: 8" UV 12" UV__ 12" EMCO 811 BK <br /> 1211 BK 12" DWP 1211 CNI 36" CNI T CsLher 12,:-_ -_ En <br /> General condition of wellhead assembly: Excellent Fair Poor <br /> Purging Equipment: _2"2" disposable bailer ��submersible pump <br /> 210 FVC bailer Dedicated bailer <br /> 4" PVC bailer Centrifugal pump <br /> Sampled with: Disposable bailer: �_P _ Teflon baLler: <br /> 1 <br /> Well Diameter: 2"-7y5:1- 4" 61t b11,- <br /> Purge Voll Multiplier: 0. 16 0. 65 1. 47 61 gal/ft. <br /> h rcre Nefts rement � ,� <br /> Time: D Time: Cal:u .ated purge: <br /> Depth of well:/ Z- ` S � Depth to water; - d Actual purge; <br /> Depth to water: 7- 15L <br /> Start purge: g Q sampling time• cf , 57- -'2- <br /> Time <br /> 7- '2-Time Temp. E.C. pH Turbidity Volume <br /> J / <br /> Sample appearance: Lock: <br /> ���rNl� - --- 11111111■IIIPIPIIglll�lllll PIYI1�IIII�P�PI.Y111 �1� -- YIYIIr iIIIIIIIIIIIIIWI11Y�111 <br /> Equipment replaced: (Check all that apply) Nate condition of replaced item <br /> 2" Locking Cap; Lock x`3753 : 7/32 Allenhead: <br /> 4" Locking Cap: Lock--Dolphin: 9/16 Bolt: <br /> 61' Locking Cap: Pinned A.l l.enhead (DWP) : <br /> Remarks: <br /> Signature: <br /> 80 3hdd so-inoa b996Z8L9Z6 8b 60 0062/bt/80 <br />