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DOULOS ENVIRONMENTAL COMPANY SAMPLING INFORMATION SHEET <br /> Client: _ Sampling Date: <br /> aSite: /Li ct6' Project No. : <br /> --r.� Well Designation: NIW`i <br /> Is setup of traffic control devices required? YES time: hours <br /> Is there standing water in well box? 0 YES Above TOC Below TOC <br /> Is top of casing cut level? NO W1 If no, see remarks <br /> Is well cap sealed and locked? NO ES If no, see remarks <br /> Height of well casing riser (in inches) : <br /> Well cover type: 811 W 1211 W 1211 EMCO 811 BK _ <br /> 1211 BK 1211 DWP 1211 CNI 3611 CNI Other <br /> General condition of wellhead assembly: Excellent c68—o d Fair Poor <br /> w i u.�uw�in - <br /> Purging Equipment: 211 disposable bailer Submersible pump <br /> 211 PVC bailer Dedicated bailer <br /> 411 PVC bailer `Centrifugal pump <br /> Sampled with: Disposable bailer: '1 Teflon bailer: <br /> Well Diameter: 2114— 4f1 611 811 <br /> Purge Vol. Multiplier: 0. 16 0. 65 1 . 47 2 . 61 gal/ft. <br /> Initial Measurement Rechar a Measurement <br />�ime: 1133 Time: it �T`�t Calculated purge:/40..Al <br /> Depth of well: Depth to water: Actual purge: _ <br /> Depth to water: I`1• _�_ <br /> Start purge: 1-L�d _ Sampling time: <br /> Time Temp. E.C. pH Turbidity Volume <br /> 1- zj-L4 <br /> Sample appearance: Lock: <br /> Equipment replaced: (Check all that apply) Note condition of replaced item <br /> 211 Locking Cap: Lock ;#3753 : 7/32 Allenhead: <br /> 411 Locking Cap: Lock-Dolphin: 9/16 Bolt: <br /> 611 Locking Cap: Pinned Allenhead (DWP) : <br /> Remarks: <br /> Signature: <br />