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Groundwater Purge and Samplarm Date: 41I % s( I`Slfnedy/Jenks Consultants <br /> PROJECT NAME: WELL NUMBER: <br /> PROJECT NUMBER: PERSONNEL: <br /> SAMPLE DATA: <br /> TIME SAMPLED: �� S S COMMENTS: <br /> DEPTH SAMPLED (FT): <br /> SAMPLING EQUIPMENT: D�SPdIz � .Ic.- <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 /> PURGE WATER DISPOSAL NOTES: ll� <br /> TOTAL DISCHARGE (GAL): H-S COMMENTS: <br /> DISPOSAL METHOD: <br /> DRUM DESIGNATIONS)/VOLUME PER (GAL): <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)?: YES NO <br /> INSIDE OF WELL HEAD AND OUTER CASING DRY?: YES NO <br /> WELL CASING OK?: YES NO <br /> COMMENTS: �e/�%y�� �'i �r 1�r /c_ <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 /> 32(589) Page 2 of 2 <br />