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bOUI+OB ramRoMIEWAL COMPANY SAMPLING INFORMATION SHEET <br /> Client: .1 3` Sampling Dater <br /> - <br /> Me <br /> Site: 9 µ " Project No. _ TL ` !y 6 n 3 <br /> A Well Designation: 41. IN <br /> Is setup of traffic control devices required? YES_ time: ou <br /> Is the <br /> re standing, watery, ins well box? E Above TOC B ow TO <br /> Is top' of casing'°cuts NO If no, see remar s <br /> Is well -cap sealed and 'locked. NO If no, see remarks <br /> Height of well•�casing riser:. {in inches} • <br /> Well cover. type:. 1.2 W 12" EMCO " BK <br /> RR := Rt $ <br /> 12 BKS_ 12+!.: Dy�p: :, M1 ! CNI" 36" CNI Other <br /> General condition'"of wellheadassembly: Excellent Good Fair Poor <br /> Purging Equipment-: <br /> g g 21V disposable bailer Submersible pump <br /> ^2g,:PVC bailer Dedicated bailer <br /> bailer <br /> Centrifugal pump <br /> Sampled with: Disposal bai,er:_ �� Teflon bailer: <br /> Well Diameter: 2"'W `. 411 I 610 811 <br /> Purge-Vol: Multiplier: > : 0. 65 1.47 2 . 61 gal/ft. <br /> Initial Measurement Rechar a Measurement <br /> Time: s. - _ Tame: 43 K9 Calculated purge: <br /> Depth of well:. .,moo, 6/;°`' Depth to water: Actual purge <br /> Depth 'to` water: <br /> eStart .ur e.= <br /> P g _ Sampling time: G1 <br /> Time. E.C._x pH Turbidity Volume <br /> . � - ..'0.s _ r.._._s'}ris..j.. •_ ..�y�.YY: <br /> 711 <br /> sq 3" - 77 2 <br /> Sample appearance:'? ,°�" .``' <br /> ;.y Lock: <br /> Equipment replaced (Check all that apply) Note condition of replaced item <br /> 2" Locking Cap.: '' - �. ::f . 'Lack 03753 : 7/32 Allenhead: <br /> 4" Locking Cap: ;, tock-Dolphin: g <br /> 6" Locking Cap: —� /16 Bolt: <br /> -ter: Pinned Allenhead (DWP) <br /> Remarks: <br /> .- -,. oX:-s r tv-• ru��,rsa,'4- ��ra++�.agh oc� ' <br /> • ... t,�� .��`/�f Hwy fk"i��F "..ru ����`_ <br /> Signature -� � <br />