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� r ,� - r _ rrK.+r.-„-'+S„'!+'tFy.tF.,+N7rMy.wiM�"q'pNkMR1MKh1r.ia.+Ple.kSupl�uw- .`Sh�vi <br /> r DOULOS ENVIRONMENTAL,INC. SAMPLING INFORMATION SHEET <br /> ClientSampling Date , -7r� <br /> Site <br /> Project No <br /> a 5 - Well Designation � <br /> � rr � <br /> 1 <br /> Is serup of traffic control devices required9 YES tune hours <br /> Is there standing water in the wall box? YES Above TQC Below TOC <br /> Is top of casing cut level? NO If no,see remarks <br /> Is well cap sealed and locked9 51- NO WD If no,see remarks <br /> Height of well casing riser(ii inches) <br /> Well cover type S" or 12"UV 12"EMCO S"or 12"BK $"Christy <br /> 12"Christy $" M&D 12"M&D 12"DWP <br /> 12"CNI 36"CNI 12"Pomaco �- Other <br /> General condition of wellhead assembly Excellent Good Pair boor <br /> Purging Equipment 2"disposable bailer r _Submersible pump <br /> 2„PVC bath Dedicated bailer <br /> 4" PVC bailer Centrifugal pump <br /> Sampled with Disposable bailer Teflon bailer Disposable Tubing <br /> Well Diameter 2" a" 6" S" <br /> Purge Vol Multiplier 0 16 065 147 2 61 gaUfl <br /> Initial Measurement Recharge Measurement <br /> Time Time, q I. Calculated purge <br /> Depth of well D - 0 y Depth to water drZ. y Actual purge <br /> Depth to water <br /> Start purge Sampling time 3 <br /> Time Tem erattire E C PH Turbidit Vohiane <br /> ` 6 <br /> l <br /> Sample appearance -�� -'"'` <br /> Lock, <br /> Equipment replaced (check all that applyy Note condition of replaced item(s) <br /> 2' Locxing Cap � _ Lacl{, `'-�`/ Allenhead <br /> 4" Locking Cap Lock-Dolphin 9116 Bolt <br /> 6" Locking Cap Pinned Allenhead(DWP) <br /> ` t <br /> Remarks <br /> Signature <br /> 6 .d 0026 13CH3SH1 dH Wd2ip :6 0002 60 ,i,dW <br />