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AdmL l <br /> 'r n <br /> undweber purge and Samp4worm Date: /i / �I I�nnedy/Jenks Consultants <br /> y= PROJECT NAME: CAP .N WELL NUMBER: <br /> _,. PROJECT SER: le IT y1-15 4"0-170 PERSONNEL:_ <br /> SAMPLE DATA: <br /> TIME SAMPLED: //: 5 S COMMENTS: <br /> DEPTH SAMPLED (FT): �I lO O <br /> SAMPLING EQUIPMENT: <br /> v <br /> NO. OF CON- FIELD VOLUME SHIPPED UNDER ANALYSIS <br /> SAMPLE CONTAIN- TAINER PRESER- FILTRA- FILLED CHAIN-OF-CUS- REQUEST <br /> NO. ERS TYPE VATIVE TION (ml or L) TURBIDITY COLOR TODY AT 4°C? (METHOD) COMMENTS <br /> /L <br /> G/S <br /> PURGE WATER DISPOSAL NOTES: <br /> TOTAL DISCHARGE (GAL): COMMENTS: <br /> DISPOSAL METHOD: <br /> DRUM DESIGNATION(S)/VOLUME PER (GAL):7 <br /> WELL HEAD CONDITIONS CHECKLIST (CIRCLE TES OR NO - IF NO ADD COMMENTS): <br /> WELL SECURITY DEVICES OK (BOLLARDS, CHRISTY LID, CASING LID AND LOCK)?: YES NO <br /> INSIDE OF WELL HEAD AND OUTER CASING DRY?. YE NO <br /> a <br /> WELL CASING OK?: YES NO <br /> COMMENTS: <br /> GENERAL: <br /> WEATHER CONDITIONS: <br /> TEMPERATURE (SPECIFY °C OR °F): <br /> PROBLEMS ENCOUNTERED DURING PURGING OR SAMPLING? <br /> CC: Project Manager: <br /> Job File: <br /> Other: <br /> F-4x2(5-89) Page 2 of 2 <br />