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t <br /> DOULOS ENVIRONMENTAL, INC SAMPLING INFORMATION SHEET <br /> Client _. Sampling Date —D <br /> • Site Project No <br /> LOQ Well Designation <br /> k serup of Traffic control devices required? O YES time hours <br /> Is there standing water in the well box? YES Above TOC Below TOC <br /> Is top of casing cut level? NO 0_� If no, see remarks <br /> Is �tiell cap scaled and locked? ® YES If no,see remarks <br /> Height of well casing riser (in inches) <br /> 1�ell co4er rype 8" or 12" UV 12" EMCO 8" or 12" BK 8" Christy <br /> 12 Chrisry 8"M&D 12" M&D 12"DWP <br /> 12 ' CNI 36"CNI 12"Pomeco Other <br /> General condition of wellhead assembly Excellent Good Fair Poor <br /> Purging Equipment 2" disposable bailer Submersible pump <br /> 2"PVC bailer Dedicated bailer <br /> 4"PVC bailer Centnfugal pump <br /> Sampied with Disposable bailer_ Teflon bailer isposable Tubing <br /> Well Diameter 2" 4" 6" 8" <br /> Purge Vol Multiplier 0 16 065 1 47 2 61 gal/ft <br /> Urinal Measurement Recharge Measurement <br /> Time - ( Time 11' Calculated purge 3 <br /> •Depth of well Depth to water _ y tK1 Actual purge <br /> Depth to water 6 <br /> Start purge / Z= 3 0 Sampling time <br /> Time Terri erature E C pH Turbidity Volume <br /> o 61 3 0 �- <br /> Sample appearance Kew_ Lock /i, <br /> Equipment replaced (check all that apply) Note condition of replaced item(s) _ <br /> 2" Locking Cap Lock 7/32 Allenhead <br /> _ 4" Locking Cap Lock-Dolphin 9116 Bolt <br /> 6" Locking Cap Pinned Allenhead (DWP) <br /> marks <br /> t <br /> Signature <br />