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DOULOS ENVIRONMENTAL COMPANY SAMPLING INFORMATION SHEET <br /> Client: Sampling Date:_, L —2 7 ;D.� <br /> ` Site: _a. zz;,� �,� ��, Project No. : <br /> PAk-/QA Rod Wel]. Designation: <br /> s <br /> GA " <br /> Is setup of traffic control devices required? YES time: hours <br />! Is there standing water in well box? <3W 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) : <br /> Well cover type: 8" UV 120' W 12" EMCO 8" BK X <br /> 12" BK 12" DWP 121' CNI 36" CNI Other <br /> General condition of wellhead assembly: Excellent qmBb Fair Poor <br /> Purging Equipment: 211 disposable bailer Submersible pump <br /> 2" PVC bailer Dedicated bailer <br /> 4" PVC bailer ��// Centrifugal pump <br /> f Sampled with: Disposable bailer: 4� Teflon bailer: <br /> Well Diameter: 2" 4" 6" 8" <br /> Purge Vol. Multiplier: 0 . 16 0. 65 1.47 2 . 61 gal/ft. <br /> Initial figgsNrement Recharge Measurement r <br /> Time. d • r � Time: = S Calculated purge: ' <br /> Depth of well: Depth to water: Actual purge <br /> Depth to water: <br /> Start purge:. Sampling time: <br /> X0 ,36 <br /> Time Temp.. E.C. pH Turbidity Volume <br /> jolt 63 • I q t 4 <br /> o <br /> 1-7 o 19 3 7- l Y ---�- 3 <br /> Sample appearance: Lock: <br /> Equipment replaced: (Check all that apply) Note condition of replaced item <br /> 2" Locking Cap: Lock 03753 : 7/32 Allenhead: <br /> 411 Locking Cap: Lock-Dolphin: 9/16 Bolt: <br /> 6" Locking Cap: Pinned Allenhead (DWP) : <br /> I <br /> Remarks: <br /> Signature: <br />