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a <br /> i <br /> wqg <br /> C <br /> Date: S / <br /> RGE AND SAMPLE FORM (cont.) <br /> Gfi011ND111fAT�Fi PU <br /> i✓ __ �--- <br /> a26—z- <br /> 1� WELL NUMBER,. <br /> PROJECT fJAML-:_c: PEI;SONNEI_:_--�— <br /> PROJECT NUME3GR: <br /> SAMPLE DAT: <br /> TIME SAMPLtiD: <br /> 7 -^• —r ------- <br /> DE-PTH SAMPLED(Et):_—� _ _ rj 1. c` <br /> SAMPLING EQUIPMENT- <br /> COMMENTS: <br /> ^� <br /> ER A!{ALYSkS C01AMOT.a <br /> - SlYPPE➢eN➢ REpUEST <br /> na-0 711Rk1k➢kTY COL OfT CkW Td vow"E �ME711D�Ot�1 <br /> or Col{YAIHER PRFSERVA1 V<C FILTRATION {ml u�Il _ C_—>r'.i <br /> SAWMC CON ugr,- TYPE -y r <br /> zvc— <br /> PURGE WATER DISPOSAL NOTES: 4� <br /> TOTAL DISCHARGE(gal)_ e <br /> DISPOSAL METHOD:---: — =!'. <br /> DRUM DESIGNATION(S)IVol-UME: _�— <br /> COMMENTS:------ _�— <br /> it NO,add comments) <br /> WELL HEAD CONDITIONS CHECICLiST <br /> Circle YES er NO-- � NO <br /> WELL SECURITY DEVICES OK(aOL1�RDS,CIdR1STY LYt�CASING LlD ANO LOCK)?: ES, . <br /> INSIDE OF WELL HEADS OUTER CASING DRY?'. <br /> WELL CASING OK. i <br /> COMMENTS: — <br /> GENERAL l? <br /> WEATHER CONDITIONS: -- <br /> TEMPERATURE(,peci1y'C1'F):---------� <br /> PROBLEMS ENCOUNTERED DURING PURGING OR SAMP <br /> COMMENTS: <br /> C.C. Project NManagor. --- <br /> Job File:�--- <br />