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Date: <br /> GIiOUNDWATEri PURGE AND SAMPLE FORM (cont.) <br /> PROJECT NAM> xKc• -,&/j-?._--_WELL NUMBER: U -------- <br /> PROJECT NUMBER:—����1 cJ PERSONNEL-.---J ✓ - <br /> SAMPLE DATA: _ <br /> TIME SAMPLED: — <br /> DEPTH SAMPLED(ft): <br /> SAMPLING EOUIPMGNT: 2 % -1\ <br /> COMMENTS: - <br /> FTCLU YOLuuf 54011'fO111+001 ARALY:IS <br /> SAMPLL 110.Of CONTAuNvi PFlESERYARVE 111.(11 7U REROiTY COL Ofi CFWNOF cU6TOUY FlGOUY.7T cOr.11.fC1i15 <br /> .Na CGNTNRERS TYPE rlLTFlATIOH ,ml�ril - AT"(Y01) - tuclmU$ <br /> > F7VOAI Aocd -FA <br /> PURGE WATER DISPOSAL NOTES: <br /> TOTAL DISCHARGE(gal): <br /> DISPOSAL METHOD: <br /> DRUM DESIGNATIONS)/VOLUME 66 1ti( <br /> COMMENTS: <br /> - <br /> WELL HEAD CONDITIONS CHECKLIST(Circle YES or NO if NO,add comments) <br /> WELL SECURITY DEVICES OK(BOLLARDS,CHRISTY�I CASING LID AND LOCK)?: YES NO <br /> INSIDE OF WELL HEAI¢AQD OUTER CASING DRY?: ES) NO <br /> WELL CASING OK?: YES' NO <br /> COMMENTS: <br /> GENERAL <br /> WEATHER CONDITIONS: <br /> TEMPERATURE(specify C/°F): <br /> PROBLEMS ENCOUNTERED DURING PURGING OR SAMPLING? <br /> COMMENTS: <br /> c.c. Project Manager <br /> Job File: <br /> Other: <br />