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1 ! <br /> 5 DOULOS ENVIRONMENTAL, INC SAMPLING INFORMATION SHEET <br /> Client Sampling Date <br /> . Site <br /> Project No <br /> t, <br /> —2,0 Well Designation M W r <br /> !: <br /> a� <br /> Is 2-erup of Traffic control devices required) YES time hours <br /> Is mere siandmg water in the well boxy S Above TOC Below TOC <br /> Is lop of casing cut lever NO If no,see remarks <br /> Is well cap sealed and lockedo NO If no, see remarks <br /> Heigh, of well casing riser(m inches) <br /> Well cover We 8' or 12" UV 12" EMCO`><, 8"or 12" BK 8"Chnsry <br /> 12 Chrisry 8 ' M&D 12"M&D 12"DWP <br /> 12 ' CN'1 36" CNl 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 Centrifugal pump <br /> Sampled with Disposable bailer Teflon bailer Disposable Tubing_ <br /> Well Diameter 2" 4" 6" 81, <br /> Purge Vol Multiplier 0 16 065 1 47 2 61 gal/ft <br /> lnival Measurement Recharge Measurement <br /> ( . Time - S3 Time Calculated purge J <br /> Depth of well ��02 Depth to water -1/q 176' Actual purge <br /> Depth to water 9 - Sl <br /> Start purge If 4 �- Sampling time <br /> Time Temperature E C RH Turbidity Volume <br /> I � 0 7 - 27 3 <br /> ---------------- <br /> Sample appearance Lock <br /> Equipment replaced {chec;: all that apply) Note condition of replaced item(s) <br /> 2" Locking Cap Lock 7132 Allerihead <br /> 4" Locking Cap Lock-Dolphin 9116 Bolt <br /> 6" Locking Cap Pinned Allenhead (DWP) <br /> SRemarks <br /> Signature <br />