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DOULOS ENVIRONMENTAL COMPANY 'c"ANWMC)� INFORMATION SHEET <br /> Client:_, _ Sampling Date: <br /> Site: Project No. : �� r-O p <br /> 4„1C,K A,, % Well Designation: MyV <br /> C' A i <br /> Is setup of traffic control devices required? YES time: hours <br /> Is there standing water in well box? Y Above TOC Below TOC <br /> Is top of casing cut level? NO If no, see remarks <br /> Is well cap sealed and locked? N E If no, see remarks <br /> Height of well casing riser (in inches) - <br /> Well cover type : e” W 12" W 121" EMCO 8" BK _ <br /> 12 '" BK 12" DWP 12" CNI 36" CNI ther <br /> General condition of wellhead assembly: Excellent Gao Fair Poor <br /> i <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: <br /> Well Diameter: 2" Y 4" 6" 8" <br /> Purge Vol . Multiplier: 0 . 16 0 . 65 1 . 47 2 . 61 gal/ft <br /> Initial Measurement Recharge Measurement <br /> Time. Time: � Calculated purge : s , � <br /> Depth of well . Depth to water: Z / Actual purge : 6 af) <br /> Depth to water• Jg'.K:!-L <br /> Start purge: JY_15 J_15Sampling time: <br /> Time Temp. E. C. pH Turbidity Volume <br /> Sample appearance: Lock: <br /> Equipment replaced: (Check all that apply) Note condition of replaced item <br /> 21' Locking Cap: Lock #3753 : 7/32 Allenhead. <br /> 4" Locking Cap: Lock-Dolphin: 9/16 Bolt , <br /> 6" Locking Cap: Pinned Allenhead (DWP) : <br /> —Remarks • <br /> i <br /> Signature - <br />