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t ��+ wy71.Yv� + •>...yZ',:r,Y. n `w+' x �y�j�`,'A�','r <br /> 1 , <br /> DOUMOS ENVIROMONTAL COXPJWY - SAMPLING INFORMATION SHEET <br />' ,� Client: Sampling Date: <br /> Site;4429,4. .A.. �.��..�� _ Project No. ; <br /> /3'600 S. Pa,-lun 1qa� Well Designation: /'I w 4=Z <br /> /_ et 2! tt <br /> 1 Is setup of traffic control devices required? YES time: hours <br /> Is there standing water in well box? a, S 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 invhes) '; <br /> Well cover type: 811 W 1.2 11 W .,. 1211 EMCO $" BK <br /> 1 1211 BR 12" DWP 1211 CNI� 36" CNI Otherg �'a�� <br /> General condition of wellhead assembly: Excellent Fair Poor <br /> Purging Equipment: 211 disposable bailer Submersible pump <br /> 2" PVC bailer Dedicated bailer <br /> 411 PVC bailer Centrifugal pump <br /> 1 <br /> Sampled with; Disposable bailer:„` Teflon bailer: <br /> Well Diameter: 2"� 411 611 811 <br /> Purge Vol , Multiplier: 0. 16 0. 65 1, 47 2 . 61 gal/ft, <br /> 1Initial meag�lreznent Recharge Mea-sureM2nt <br /> Time:12:6 _ Time; a.fS 7 Calculated purge: <br /> Depth of well : S Depth to water; •fit Actual purge; <br /> Depth to water; <br /> T start purge : -�04 sampling time: g` <br /> Time Temp.. . E.C. pH Turbidity Volume <br /> 1 <br /> Im e 2 I IR- 3 Ka os- <br /> Sample <br /> Sample appearance; Lock: fin!✓G <br /> Equipment replaced: (Check all that apply) Note condition of replaced item <br /> 2" Locking Cap: Lpck #3753 ;______ 7/32 Allenhead; <br /> 41' Locking Cap; Lock-tolphJp:� 9/16 Bolt: <br /> 6" Locking Cap: ,< Pinned A1Lenhead (DWP) : <br /> •�. —- - yrs.._ —I i r;r u ■ , r i r i �r�n � <br /> N <br /> Remarks : <br /> i <br /> r r <br /> l <br /> J <br /> Signature : <br />