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_{ I <br /> GROUNDWATER PURGE AND SAMPLE FORM (cont_) Date- <br /> F <br /> E 6vxon ' 39 4 Z WELL NUMBER vzBER gra 7'Z9, 14(o S PERSONNEL- KL MW <br /> EDPLED (ft) <br /> SAMPLING EQUIPMENT- Su. `3p iaQk it r <br /> COMMENTS ' <br /> SAMPLE NO OF <br /> ND CONTAINERS PRESERVATIVE <br /> PRESERVATIVE FIELD VOLUME SHPPED UNDER ANALYSIS v <br /> TYPE RLTRATION FILLED 7L)RQID1Ty COLOR CHAINOFCUSTODY REQUEST <br /> (ml or n AT{'C(YAJ) (MET}IOD) COMMENTS <br /> f <br /> VOA } (Q / 1#Q `� I o C Yes TP+�✓e s �TrrX <br /> i <br /> 1 <br /> PURGE WATER DISPOSAL NOTES: <br /> TOTAL DISCHARGE (gal) ' 1 <br /> DISPOSAL METHOD �5 Covt c{�-Lcm <br /> DRUM DESIGNATION(S)NOLUME- TA L1el <br /> COMMENTS <br /> WELL HEAD CONDITIONS CHECKLIST(Circle YES or NO -- if NO, add comments) <br /> WELL SECURITY DEVICES OK (BOLLARDS, CHRISTY LID, CASING LID AND LOCK)?- NO <br /> INSIDE OF WELL HEAD AND OUTER CASING DRY? �S NO <br /> WELL CASING OK? ES NO <br /> COMMENTS J17 , <br /> GENERAL <br /> WEATHER CONDITIONS- <br /> TEMPERATURE (specify oC/oF) <br /> PROBLEMS ENCOUNTERED DURING PURGING OR SAMPLING'2 <br /> COMMENTS Le_ — <br /> c c- Project Manager ' <br /> .lob File <br /> Other <br />