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t h .5 � a r.�.s .. ry w.. �r w.. ✓ ... r ti.r• r v. <br /> 1 <br /> 1>0tTLO8 ENVIRONXENTAL COMPANY SAMPLING INFORMATION SHEET <br /> Client: Sampling Date: <br /> 1 -0 <br /> 1 Site; Ag=& Project No. ; <br /> N0k-/un Well Designation: <br /> ft <br /> 1 Is setup of traffic control devices required? YES time: hours <br /> Is there standing water in well box? YES 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) : -16 <br /> Well cover type: 8" UV12 It W 12" EMCO y� 8" BK�� /i <br /> 1 <br /> 1211 BK 1211 DWP 1211 CNI_� 3611 CNI Others 0 Iz � L3 <br /> General condition of wellhead assembly: Excellent o Fair Poor <br /> Purging Equipment: 2" disposable bailer Submersible pump <br /> 2" PVC bailer Dedicated bailer <br /> 4" PVC bailer 2=centrifugai pump <br /> 1Teflon bailer: <br /> Sampled with: Disposable bailer: <br /> Well Diameter: 2" 4" 6" 8" <br /> Purge Vol . Multiplier: 0. 16 0. 65 1.. 47 2 . 61 gal/ft. <br /> Initial m2nt $gcharcre Measurement <br /> Time: / Time: II = 5<p Calculated purge . <br /> Depth of well : J � -� Depthtowater: 1U ' 5'C? Actual purge . <br /> Depth to water: • <br /> Start purge: 1 : L/ 0 Sampling time: <br /> i <br /> 57 A'OL— <br /> Time Temp. . E.C. pH Turbidity Volume <br /> 111 % -7 C(0 7 , / D <br /> Sample appearance: Lock: <br /> Equipment replaced: (Check all that apply) Note condition of replaced item <br /> 2" Locking Cap: Lock #3753 : 7/32 Allenhead: <br /> 4" Locking Cap: Lock-Dolphin; 9/16 Bolt : <br /> 611 Locking Cap: Pinned Allenhead (DWP) : <br /> Remarks : <br /> I <br /> Signature : <br />