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DOULOS ENVIRONMENTAL COMPANY SAMPLING I FORM--TION SHEET <br /> �. Client: /}_ a Sampling Date: <br /> Site : _��,�c, Project No. : <br /> 1 1 <br /> Well Designation: Lx <br /> Is setup of traffic control devices required? NO Y time: hours <br /> 1 Is there standing water in well box? 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 11 W 1211 UV 1211 EMCO 8 11 BK <br /> 1211 BK 1211 DWP 1211 CNI 3 611 CNI her' 1E0 rr 1 <br />` General condition of wellhead assembly; Excellent Good Fair Poor <br /> Purging Equipment: 2T1 disposable bailer Submersible pump <br /> 211 PVC bailer Dedicated bailer <br /> 4T1 PVC bailer Centrifugal pump <br /> ,t <br /> Sampled with: Disposable bailer; Teflon bailer: <br /> Well Diameter; 211X 411 611 811 <br /> Purge Vol . Multiplier: 0 . 16 0. 65 1. 47 2 . 61 gal/ft . <br /> e!,AsNrement a • <br /> Time : 7. S3 Time :. Calculated purge: .S. <br /> Depth of well : Depth to water: Actual purge; <br /> Depth to water: <br />'T Start purge : � `3� Sampling time: 0 <br /> Time Temp. E. C. pH Turbidity Volume <br /> Sample appearances Lock: 1 <br /> Equipment replaced: (Check all that apply) Note condition of replaced item <br /> 211 Locking Cap: Look #3753 : 7/32 Allenhead: <br /> 411 Locking Cap: Lock-Dolphin: 9/16 Boat; <br /> 611 Locking Cap: Pinned Allenhead (DWP) : <br /> • Remarks : <br /> 1 <br /> 1 <br /> Sig-nature: .' <br />