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DOULOS ENVIRONMENTAL, INC. SAMPLING INFORMATION SHEET <br /> Client Uro Sampling Date — <br /> Site- �e a Project No <br /> 1411:4 C .je:�fze_ Well Designation _ <br /> Is setup of traffic control devices required9 YES time fours <br /> Is there standing water in the well box? 0 YES Above TOC Below TOC <br /> Is top of casing cut lever NO If no, see remarks <br /> Is well cap sealed and locked? NO c If no, see remarks <br /> Height of well casing riser(in niches) <br /> Well cover type 8"or 12"W 12"EMCO 8"or 12"BK 8" Christy <br /> 12"Christy 8"M&D_7)�'_ 12"M&D 12"DWP <br /> 12" CNI 36" CNI 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" 8" <br /> Purge Vol Multiplier 016 065 147 2 61 gal/ft <br /> Initial Measurement Recharge Measurement <br /> Time = Time I 'a� Calculated purge 1 <br /> Depth of well Depth to water, _ Actual purge � <br /> Depth to water 9,3, 7 9 <br /> Start purge f Sampling time 1 1 <br /> Time Temperature E C pH Turbidity Volume <br /> ' G19 <br /> Sample appearance Lock <br /> Equipment replaced (check all that apply) Note condition of replaced item(s) <br /> 2" Locking Cap Lock 7/32 Allenhead <br /> 4"Locking Cap Lock-Dolphin 9/16 Bolt <br /> 6" Locking Cap Pinned Allenhead (DWP) <br /> emarks — <br /> S ignature <br />