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GROUNDWATER PURGE AND SAMPLE FORMco Date --2 •9Z <br />' PROJECT NAME. � 7-% nt.)WELL NUMBER. <br /> PROJECT NUMBER 10V19, PERSONNEL- w <br />' SAMPLE DATA: <br /> TIME SAMPLED /-2-O D <br /> DEPTH SAMPLED (ft) '�4 r-7-- <br />' SAMPLING EQUIPMENT <br /> COMMENTS ry <br /> 1 <br /> SAMPLE NO,OF CONTAINER HELD VOLUME <br /> NSIiPPEP UNDER ANALYStS <br /> RL7RATION' O CONTAINERS TYPE PRESERVATIVE FILLED TURINDITY COLON CNAINOFCUSTOOY REOIIEST <br /> (ml or l) ATi`C(Y" (METHO11) COMMENTS <br /> //maw !�� L W <br /> .3 �i� �3rt< 5 <br />' PURGE WATER DISPOSAL NOTES- <br /> TOTAL DISCHARGE (gal)�3 S <br /> DISPOSAL METHOD <br /> DRUM DESIGNATION(S)NOLUME 1i► <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)? Ip <br /> INSIDE OF WELLHEAD AND OUTER CASING DRY?. �NO <br />' WELL CASING OK? NO ---- <br /> COMMENTS lV0 <br /> GENERAL <br /> WEATHER CONDITIONS SP°`� ver J <br /> TEMPERATURE (specify OC/OF) <br /> PROBLEMS ENCOUNTERED DURING PURGING OR SAMPLING? <br /> COMMENTS <br /> cc Project Manager <br /> Job Fdo <br /> Olhor <br /> I <br />