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• DOULOS ENVIRONMENTAL, INC. SAMPLING INFORMATION SHEET r <br /> Client , 5iyUl r� ,.�t.t�i a--�, Sampling Date -- <br /> • Site (51 4-t VI a 1, VA, Project No <br /> lei. � Well Designation <br /> Sia�L a 4f <br /> Is setup of traffic control devices required9 YES time hours <br /> Is there standing water in the well box? �W- 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 If no, see remarks <br /> Height of well casing riser(in inches) <br /> Well cover type 8"or 12"W 12"EMCO 8"or 12"BK 8" Christy <br /> 12"Christy 8"M&D12"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 0 16 065 147 2 61 gal/ft <br /> Initial Measurement Recharge Measurement <br /> Time ' Time j,0: " Calculated purge .Q <br /> Depth of well C) Depth to water Actual purge <br /> Depth to water :�Z3 <br /> Start purge 0,' Sampling time <br /> Time Temperature EC pH Turbidity Volume <br /> 17 <br /> s� <br /> z <br /> Sample appearance Lock OCJ 1'0A In <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 /> • Remarks <br /> Signature <br />