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1 <br /> DOULOS ENVIRONMENTAL COMPANY SAMPLING INFORMATION SHEET <br /> Client Al2- CO <br /> CQ 91 Sampling Date: <br /> Site 1 6 Project No. : <br /> X CXtf f0 N11? Well Designation : ' <br /> Is setup of traffic control devices required YES time - hours <br /> Is there standing water in well box? YES Above TOC Below TOC <br /> Is top of casing cut level? NO If no, see remarks <br /> Is well cap sealed and locked' NOIf no, see remarks <br /> Height of well casing riser ( in inches) : 21 <br /> Well cover type : 8" UV 12 " UV 12" EMCO 81" SK <br /> � <br /> 12 " BK 12 10 DWP 121" GNI 3611 CNI Other � r <br /> General condition of wellhead assembly: Excellent Fair Poor <br /> Purging Equipment : 2" disposable bailer _Submersible pump <br /> 21' PVC bailer Dedicated bailer <br /> 41" PVC bailer centrifugal pump <br /> Sampled with Disposable bailer: S Teflon bailer: <br /> Well Diameter• 2'" 411 /\ 61" 811 <br /> Purge Vol Multiplier: 0 . 16 0 . 65 1 . 47 2 . 61 gal/ft <br /> Initial Measurement Rec ar e Measurement <br /> Time Time._ �_ calculated purge . <br /> Depth of well . 6 d Depth to water: O purge <br /> Depth to water, aq <br /> Start purge : / Sampling time: <br /> Time Temp. E. C. pH Turbidity Volume <br /> 06 <br /> Sample appearance: Lock: <br /> Equipment replaced . (Check all that apply) Note condition of replaced item <br /> 2 " Locking Cap: Lock 13753 : 7/32 Allenhead . <br /> 4 " Locking Cap, Lock-Dolphin: 9/16 Bolt - <br /> 61" Locking Cap, Pinned Allenhead (DWP) <br /> Remarks <br /> Signature : <br />