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�i <br /> DOULOS ENVIRONMENTAL, INC SAMPLING INFORMATION SHEET <br /> a <br /> 3 <br /> Client Sampling Date <br /> Site <br /> Project Na <br /> Z� Well Designation — /✓I w r <br /> Is setup of traffic control devices required � YES time hours <br /> Is there standing water to the well box? YES Above TOC Below TOC <br /> Is top of casing cut level9 NO If no,sec remarks <br /> is welt cap sealed and locked NO If no, see remarks <br /> Height of well casing riser (in inches) <br /> Well cover rype 8" or 12"UV 12" EMCO 8" or 12" BIC 8" Christy <br /> 1? Chrtsry 8" M&D 12"M&D 12" DWP <br /> 36" CNI 12" Pomeco Other <br /> General condition of wellhead assembly Excellent GoodW Fair Poor <br /> Purging Equipment 2" disposable bailer Submersible pump <br /> 2" PVC bailer Dedicated bailer <br /> 4" PVC bailer Centrifugal pump <br /> Sampled with Disposable bailer Teflon bailer Disposable Tubing <br /> Well Diameter 2" 4" 6" 8" <br /> Purge Vol Multiplier 0 16 065 1 47 2 61 gal/ft <br /> Initial Measurement Recharge Measurement <br /> ; <br /> Time _ Lo• ©O Time� _ __W_ _ 30 Calculated purge <br /> Depth of well 7- Depth to water tic) Actual purge <br /> Depth to water Va - '7 <br /> y Start purge j Sampling time <br /> f <br /> ' Time Temperature EC pH Turbidity Volume <br /> Sample appearance Lock 4✓ - <br /> Equipmr,rit rcplaccd (chcc.k all that apply) Note conaition 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 /> Remarks <br /> 5,mature <br />