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i <br /> DOQLOS ENVIRONMENTAL COMPANY SAMPLING INFORMATION SHEET <br /> Client: _ . <br /> 4�-.Sampling Date: f- 7 <br /> site• 4141M ' f y_ Project No. : <br /> 1 <br /> 164�90 LetteaWell Designation: <br /> De, G A <br />` 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? NO3 If no, see remarks <br /> Height of well casing riser (in inches) : <br /> Well cover type: 8" UV12" W 12" EMCO 8" BK <br /> 12" BK 12" DWP 12" CNI 36" CNI Other ? M o f'5_t <br /> 1 General condition of wellhead assembly: Excellent 42MO Fair Poor <br /> Purging Equipment: 2" disposable bailer Submersible pump <br /> 211 PVC bailer Dedicated bailer <br /> 4" PVC bailer _74Centrifugal pump <br />/ Sampled with: Disposable bailer:_ Teflon bailer: <br /> Well Diameter: 2" 4" 6" 8" <br /> Purge Vol. Multiplier: 0. 16 0.65 1. 47 2 . 61 gal/ft. <br /> rAWnitia MRASU. pment gggharge MeAsurement <br /> ImPTIme: ff =OTime: 9 �G'Y Calculated purge: <br /> Depth of well: ��`� 3 Depth to water: Cl 6 Actual purge <br /> Depth to water:. • <br /> Start purge: 9' 569 Sampling time: a <br /> Time Temp. . E.C. pH Turbidity Volume <br /> �:Sr 63 - a � a � • � �' I <br /> =53 � 3• / Yg o 'd • C7 d <br /> 1 <br /> 1 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 /> 4" Locking Cap: Lock-Dolphin., 9/16 Bolt: <br /> 6" Locking Cap: Pinned Allenhead (DWP) : <br /> Remarks: <br /> Signature: <br />