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Date_ <br /> GROUNDWATER PURGE AND SAMPLE FORM (cont.) <br /> PROJEC`17 NAME -Cl-/�IJft0 ss9 -�91gWELL NUMBER'_ — <br /> PRO.)E .T NUMBER PERSONNEL <br /> SAMPLE DATA: <br /> TIME SAMPLED `T <br /> rt <br /> DEPTH SAMPLED(ft) 57 <br /> SAMPLING EQUIPMENT L ASL <br /> COMMENTS <br /> YOI UME SHPPED i1NDER ANALr= <br /> SAMPLE Nov OF CONTAINER HELD FILLED TURBIDITY COLOR CHAIN OF CUSTODr REQUEST COMMENTS <br /> PRESERVATIVE RLTRATIOM AT 4'C(YIN (MEIHOM <br /> }IOC CONTAINERS TYPE {ml u q <br /> CSR. Qd/$ 6,9S <br /> 3 1/afa 1 ojeY Y hoz <br /> ---------- ............. <br /> PURGE WATER DISPOSAL NOTES:3s <br /> TOTAL DISCHARGE (gal) <br /> DISPOSAL METHOD R th" <br /> DRUM DESIGNATION(S)/VOLUME <br /> COMMENTS <br /> WELL HEAD CONDITIONS CHECKLIST (Circle YES or NO--if NO, add comments) <br /> WELL SECURITY DEVICES OK(BOLLARDS, CHRISTY LID CASING LID AND LOCK)?. NO <br /> INSIDE OF WELL HEAD AND OUTER CASING DRY? ES NO <br /> WELL CASING OKI NO <br /> COMMENTS <br /> GENERAL <br /> WEATHER CONDITIONS OAZ`f L - L ccoy <br /> TEMPERATURE (specify QCrF) �D F <br /> PROBLEMS ENCOUNTERED DURING PURGING OR SAMPLING? <br /> COMMENTS <br /> cc Project Manager <br /> Job File Oil <br /> Other <br />