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I�r +-i.. r•M'+. ... .. i ir.ne-vlr.t rerJ✓t4 .'TwA+n <br /> , 'i <br /> Y..'`i' tIZ <br /> t <br /> DOIILOS ENVZROWNTAL COMPANY SAMPLING INFORMATION SHEET <br /> Client: Sampling Date:/2 -/o -on <br /> S i t e Project No. : <br /> r <br /> 6'6 'L .L21,em Ra( Well Designation: <br /> Z_ 7f- <br /> M Is setup of traffic control devices required? time; hours <br /> is there standing water in well box? NO 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" UV12" W 12" EMCO " BK <br /> 12" BK 1.2" DWP12" CNI 36" CNI Other �'�t r[1 <br /> General condition of wellhead assembly: Excellent Good Fair P r <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: 2';4K 4" 6" 8" <br /> • Purge Vol . Multiplier: 0 , 16 0. 65 1.47 2 . 61 gal/ft. <br /> -� <br /> Time : Time; Calculated purge <br /> Depth of well ; $ Depth to water: 3 Actual purge : <br /> Depth to water: <br /> Start purge : Sampling time: <br /> Time Temp.. . EX. pH Turbidity Volume <br /> Sample appearance: Look: <br /> Equipment replaced: (Check all that apply) Note condition of replaced item <br /> 2" Locking Cap: Look 03753 : 7/32 Allenhead: <br /> 4 " Locking Cap: Lock-Dolphin: 9/1.6 Bolt; <br /> 6" Locking Cap: Pinned Allenhead (DWP <br /> Remarks : <br /> I <br /> Signature : <br />