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" � .__ " .. _ r .a.wtl rr'+.•�•F��dbl�}Sf'1'.'if" •i s <br /> r r is 1 t'ij•f,.r ' <br /> z <br /> DOQLOB ENVIROKUNTAL COMPANY SAMPLING INFORMATION SHEET <br /> 4'10 Client , Sampling Date:_ r <br /> I <br /> site: Project No. : <br /> / n Well Designation: <br /> I Is setup of traffic control devices required? NO YES time: hours <br /> Is there standing water in well box? NO YES Above TOC Below TOC <br /> Is top of casing cut level? - NO YES If no, see remarks <br /> Is well cap sealed and locked? NO eJES if no, see remarks <br /> Height of well casing riser (in inches) : <br /> Well cover type: 8" W,. 12" W— 12" EMCO 8" BK <br /> 1,2" BK 12" DWP 12" CNI_ 36" CNI ther,�LJ- _ <br /> General condition of wellhead assembly: Excellent Fair Poor <br /> purging Equipment: 2" disposable bailer Submersible pump <br /> 2" PVC bailer Dedicated bailer <br /> 4" PVC bailer =!C— .Centrifugal pump <br /> I <br /> Sampled with: Disposable bailer:_ ,L Teflon bailer: <br /> Well Diameter: 2" 4" 611 811 <br /> Purge Vol . Multiplier: 0. 16 0, 65 1. 47 2 , 61 gal/ft <br /> • Time : Time: / - Calculated purge . S 3 <br /> Depth of well ! _ S1� Depth to water;_ g. Q_ Actual purge . 5.S ._ <br /> Depth to water; 2 <br />�i Start purge: • � � Sampling time: <br /> Time Temp.... E. C. PH Turbidity Volume <br /> I <br /> Sample appearance: Lock: /Ie�PAle <br /> Equipment replaced: (Check all that apply) Note condition of replaced -ten <br /> 2 " Locking Cap: Lock 03753 : 7/32 Allenhead . <br /> 4 " Locking cap; Lock-Dolphin; 9/16 Bolt : <br /> 5" Locking Cap: Pinned Allenhead (DWP) : <br /> Remarks : <br /> 1 <br /> Signature : <br />