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'^' � '+-..4°...h "yPC�.—rx wlgfv�^•.x��Y`:7•n r.++..+Arra'. +.t'.av+W4'Ic�.r Vis. a�""Pf�^`c 'a Y+ s r .� i�< .F f i a _. .. <br /> � r <br /> DOULOS ENVIRONMENTAL, INC, SAMPLING INFORMATION SHEET <br /> Client1 = _ Sampling Date d o <br /> . Site aztel":1 JX-1-1 Project No <br /> Well Designation <br /> 1 <br /> A <br /> I <br /> 1�, serup of traffic control devices required9 YES time hours <br /> Is there standing water to the well box9 Y S Above TOC Below TOC <br /> Is top of casing cut level9 NO If no,see remarks <br /> Is well cap sealed and locked' NO If no,see remarks <br /> Height of well casing riser(in inches) <br /> ' Well coFer type 8 ' or 12" UV 12"EMCO 8" or 12" BK 8" Christy <br /> 12 Chrisry8" M&D 12"M&D 12"DWP <br /> 12 CNI 36" CNI 12"Porneco 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 /> Sampled with Disposable bailer S Teflon bailer Disposable Tubing <br /> Well Diameter 2" 4"�_ 6" 8" <br /> Purge Vol Multiplier 016 065 1 47 2 61 gal/ft <br /> lnirial Measurement Recharge Measurement <br /> Time G e L(O Time / Calculated purge <br /> .Depth of well 6 � ' C Depth to water Ole Actual purge <br /> Depth to water Ll 6 <br /> d <br /> Start purge !�' L/ O Sampling time = 0 <br /> I <br /> Time Temperature E C 2H Turbidity Volume <br /> IoGZ 7 - 7V <br /> 1 , 32S -7 - 32- <br /> Sample <br /> ample appearance Lock <br /> OL <br /> Equipment replaced (check all that apply) Note condition of replaced item(s) <br /> 2" Locking Cap Lock 7132 Allenhead <br /> 4" Locking Cap Lock-Dolphin 9/16 Bolt <br /> 6" Locking Cap Pinned Allenhead (DWP) <br /> �emarks <br /> 8 <br /> Signature <br />