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DOQLOS ENVIRONMENTAL COMPANy SAMPLING INFORMATION SHEET <br /> . Client • Sampling Date. � � �L - Grp <br /> Site. 1 Pro3ect No <br /> C Well Designation• ?1-1 W 3 <br /> Is setup of traffic control devices required? M YES time- <br /> Is there standing water in well box? hours <br /> Is top of casing cut level? YES Above TOC Below TOC <br /> NO <br /> Is well cap sealed and locked"P If no, see remarks <br /> Height of well casing riser (in inches) : <br /> NO If no, see remarks <br /> dell cover type : 8" UV 12" W ) „ <br /> �� 12" EMCO 8 BK <br /> 12 BK 12 " DWP 12" CNI 36" CNI Other <br /> General condition of wellhead assembly: Excellent oo Fair Poor <br /> Purging Equipment: 2�' disposable bailer _•�Submerslble pump <br /> 2 PVC bailer Dedicated bailer <br /> 4 " PVC bailer Centrifugal pump <br /> Sampled with: Disposable bailer:,_ Teflon bailer. <br /> Well Diameter: 2"-lynl' 4" 6" Sri <br /> . Purge Vol . Multiplier: 0 . 16 0. 65 1. 47 2 61 gal/ft <br /> Tnit al Measurement ec a �eMe�asuremnent <br /> Tine / 7 � Time:_ f Calculated purge I <br /> Depth of well : Depth to water Actual purge <br /> Depth to water 3 - <br /> Start purge . Sampling time: S *f <br /> Time Temp. E. C. pH Turbidity Volume <br /> 91 <br /> Y3 t5 7 <br /> � • 4 7 • .qg <br /> Sample appearance: _ ccs 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: <br /> 6" Locking Cap: 9/15 Bolt : <br /> • Pinned Allenhead (DWP) : <br /> Remarks . <br /> Signature <br />