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t SAMPLING INFORMATION SHEET <br /> Client Sampling Date: <br /> Site Project No ___-- <br /> i� Well Designation �LrktJ <br /> 1s setup of traffic control devices required? YES time, Fours <br /> Is there standing water in tilt well box? YES Above TOC Below TOC <br /> IQIs tap of casing cut levels NOAn- If no, see rcmarks <br /> is well cap sealed and locked? NO If no, see remarks <br /> Height of well casing nser(in inches) <br /> Well cover type 8"or 12"W 12"EMCO _ 8"or 12"BK 8"Christy <br /> l2"Chnsty _ 8"M&D� 12"M&D 12"DWP <br /> 12"CNl 36"CNI 12"Portico Other <br /> General pond,tion of wellhead assembly Excellent Good Pan' Poor <br /> Purging Equipment 2" disposable bailer Submersible pump <br /> 2"PVC bailer Dedicated bailer <br /> 4"PVC banes Centrifugal pump <br /> Sampled with Disposable bailer Teflon bailer Disposable Tubing_ <br /> Well Diameter: 2" 41' 61" S" <br /> Purge Vol Multiplier 0 6 065 147 2 61 gal/ft <br /> Initial Measurement Recharge Measurement <br /> Time Time 64)- Calculated purge 2. <br /> Depth of well 1-7 Depth to water _ �.1� Actual purge i—1..q'i, <br /> Depth to,water. )-.1.0 <br /> Start purge /03-S _ _ Sampling time. 1 b 43 - <br /> ",Time J, Temperature E.0 pH Turbidity Volume <br /> Sample appearance, Lock <br /> Equipment r laced (check all that apply) Note condition of replaced item <br /> replaced pY � s( � <br /> 2" Locking Cap, Lock. 7/32 Allenliead- <br /> 4" Locking Cap Lock-Dolphin- 9/16 Bolt <br /> 6" Locking Cap Pinned Allenhead (DW) <br /> r <br /> Remarks `1 <br /> r <br /> Signature <br />