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� Datfi: 3•Z�'�I <br /> GROUNDWATkfl PURGE AND SAMPLE FORM jL)/ <br /> vt/I�,tJ <br /> PROJECT NAME: f O5d WELL NUMBER:---- <br /> "-''ROJECT NUMBER: IO Z`' I PERSONNEL: U <br /> SAMPLE DATA: Z+Q <br /> TIME SAMPLED' �Z <br /> DEPTH SAMPLED(tl): <br /> ' SAMPLING EQUIPMENT: <br /> COMMENTS: <br /> Slai'i'EOUfIOUi ^' AitALY575 GO4iAiLH75Y'#f4 y, <br /> 4 t++i YOI.[{rJL 'liCUilfST <br /> � nt�[o, lUliO7OliY COLOR .•GIWIi OF G1J TORY ' . , ,:.......1..-, <br /> GONYA1NLfK PE EA _ C'�.RyASNE F1LT'MT50f1 f• '" r.-'.. a AT�;CfYM) r :(YLi110dI.,., <br /> SAt�LE: $ rtJ a it.._�'_ .• . <br /> .,� • <br /> WA / ------- <br /> I . <br /> PURGE WATER DISPOSAL NOTES: uy <br /> TOTAL DISCHARGE(gal): 4 <br /> DISPOSAL METHOD: <br /> SS <br /> DRUM DESIGNATION(S)NOLUME: <br /> COMMENTS: <br /> WZL HEAD CONDITIONS CHECKLIST(Circle YENRISTY Ltd,NO, <br /> �fid Co DAND LOCK)?. � NO <br /> WELL SECURITY DEVICES OK(BOLLARDS,C <br /> INSIDE OF WELL HEAD AND OUTER CASING DRY?: NO <br /> W ELL CASING OK?: NO <br /> COMMENTS: <br /> GENERAL <br /> WEATI-iER CONDITIONS: Q <br /> TEMPERATURE($Pcdty QcrF): <br /> PROBLEMS ENCOUNTERED DURING PURGING OR SAMPLING? � <br /> - COMMENTS: <br /> c.c. Project NManacgec <br /> Job File: <br /> Other. <br />