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DOOLOS ENVIRONMENTAL COMPANy SAMPLING INFORMATION SHEET <br /> Client: i �mQ!ti, _ Sampling Date : <br /> Project No. <br /> Xec/rLt Well Designation: <br /> G7q I <br /> Is setup of traffic control devices required7 � YES time hours <br /> O <br /> Is there standing water in well box? YES Above TOC Below TOC <br /> Is top of casing cut level? No E If no , see remarks <br /> Is well cap sealed and locked? NO ES If no, see remarks <br /> Height of well casing riser ( in inches) : 3 <br /> well cover type : S" LTV 12" LTV 12" EMCO 8 " BK <br /> 12 " BK 12 " DWP 12 " CNI 36" CNI Other 1,L /Y1 <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 /> Well Diameter: 211 4 61r 811 <br /> Purge Vol . Multiplier: 0 . 16 0 . 65 1 47 2 61 gal/ft <br /> initial Measurement Recharae MPAqllrzment <br /> Time _ 7 .1-0 Time: Calculated purge <br /> Depth of well 5�;7- 0 Depth to water: - Actual purge <br /> Depth to water :_ YZ J`� <br /> Start purge . q 00 Sampling time: R I / <br /> Time Temp . E. C. pH Turbidity Volume <br /> 0 6LI, S7ga - � <br /> C/ <br /> 0 X60 7 /0 --- y <br /> Sample appearance: �v „� 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 />