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1 <br /> DOOLOS ENVIRONMENTAL COMPANY SAMPLING INFORMATION SHEET <br /> Client: Sampling Date: - 3 © ' 0/ <br /> Site; �n,uc�,.f 0Project No. <br /> I <br /> /iWell Designation: M w r <br /> Is setup of traffic control devices required? o YES time: hours <br /> Is there standing water in well box? YE Above TOC Below TOC <br /> Is top of casing cut level? NO If no, see remarks <br /> Is well cap sealed and locked? NO (!MP If no, see remarks <br /> Height of well casing riser (,in inches) ; <br /> Well cover type; 8" W 12" W 1.2" EMCO 811 BK <br /> 12" BK 12" DWP 12" CNI 36" CNI Other <br />! General condition of wellhead assembly: Excellent Co) Fair Poor <br /> Purging Equipment; 2" disposable bailer Submersible pump <br /> 2" PVC bailer Dedicated bailer <br /> 4" PVC bailer =6entrifugal pump <br />! Sampled with: Disposable bailer: /Y- <br /> ,.— Teflon bailer: <br /> Well Diameter: 2" 4++ 6" 811 <br /> Purge Vol. Multiplier: 0 . 16 0. 65 1. 47 2 . 61 gal/ft. <br /> Initial asu <br />! Time: 8 5 7 Time: / Calculated purge: <br /> Depth of well : Depth to water: o Actual purge; <br /> Depth to water: <br /> Start purge: Sampling time: / 6 <br />! Time Temp. E. C. pH Turbidity Volume <br /> �? o l 1 7 - ( ( <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 /> 6" Locking Cap: Pinned Allenhead (DWP) : <br /> • Remarks: <br /> Signature: <br />