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DOULOS ENVIRONMENTAL COMPANY SAMPLING INFORMATION SHEET <br /> Client; Sampling Date: Z21 2:a <br /> Site : Project No. : <br /> G, _ agMJG4n , �gZ Well Designation: y <br /> H-O4 4 <br /> i.�rrrr�.�a n i i i u..ri _ .....rrri�� ��r—i�nr•.r.ru. <br /> Is setup of traffic control devices required? 'YES time: hours <br /> M Is there standing water in well box? a Above TOC Below TOC <br /> Is top of casing cut level? NO If no, see remarks <br /> Is well cap sealed and locked? NO If no, see remarks <br /> Height of well casing riser (in inches) : <br /> Well cover type: 8" W 12'f W 12 " EMCO 8" BK <br /> 1211 BK 12" DWP 12t' CNI 3611 CNI e - r�- <br /> ZdB <br /> 1General condition of wellhead assembly: Excellent Fair Poor <br /> Purging Equipment: 211 disposable bailer Submersible pump <br /> 2" PVC bailer Dedicated bailer <br /> 4" PVC bailer Centrifugal pump <br /> 1 Sampled with; Disposable bailer: Teflon bailer: <br /> Well. Diameter; 2117YL 4" 6" 8" <br /> Purge Vol . Multiplier: 0 . 16 0. 65 1, 47 2 , 61 gal/ft. <br /> Initial Mesurement Recharcre Measurementn <br /> 1 Time: :3 Time: 'Z Calculated purge; <br /> Depth of well : • 5� Depth to wa er: 9 Actual purge :_ <br /> Depth to water: y_ �"' <br /> 'r Start purge: -��� Sampling time: - <br /> 1 Time Temp. E. C, pH Turbidity Volume l <br /> Ce <br /> 1 Sample appearances Lock; <br /> Equipment replaced: (Check all that apply) Note condition of replaced item <br /> 2" Locking Cap: Lock 13753 : 7/32 Allenhead: <br /> 4" locking Cap; Lock-Dolphin: 9/16 Bolt; <br /> 6" Locking Cap: Pinned Allenhead (DWP : <br /> 1 <br /> . Remarks: <br /> 1 signature: <br />