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DODLOS ENVIRONMENTAL COMPANY SAMPLING INFORMATION SHEET <br /> Client: l �� Sampling Date: ~� - 4© <br /> Site: , 6�}� _ Project No. <br /> I3. idFw � <br /> _ cr/hlirrt,Qly..r��►L.- Well Designation: <br /> G <br /> Is setup of traffic control devices required YES time: hours <br /> Is there standing water in well box? Y S Above TOC Below TOC <br /> Is top of casing cut level? NO If no, see remarks <br /> Is well cap sealed and locked> NO3 If no, see remarks <br /> Height of well casing riser (in inches) : _ <br /> Well cover type: 6" UV 12" UV 12" EMCO 8" BK <br /> 12" BK 12" DWP 12" CNI 36" CNI Other J i- SM_1_ <br /> General condition of wellhead assembly. Excellent o 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: S Teflon bailer: <br /> Well Diameter: 211 <br /> --L 4" 6" 8" <br /> Purge Vol . Multiplier: 0 16 0. 65 1 47 2 . 61 gal/ft . <br /> Initial Measurement Recharcre Measurement 3 S, <br /> Time . SO Time: Calculated purge: <br /> Depth of well : SS_15' Depth to water: S� 3 Actual purge 3;s <br /> Depth to waters <br /> Start purge • a 2 2- Sampling time: �J <br /> Time Temp. E. C. pH Turbidity Volume <br /> /0/0 � ► <br /> 2d 70 •� q l 7 ZC�t7 70 - 9 qG 712 –t— I <br /> -r-� <br /> Sample appearance: Lock : <br /> Equipment replaced: (Check all that apply) Note conditi n of replaced item <br /> 2" Locking Cap: Lock 03753 : 7/32 Allenhead: <br /> 4" Locking Cap: Lock-Dolphin: 9/16 Bolt: <br /> 6" Locking Cap: Pinned Allenhead (DWP) : <br /> 41 Remarks: <br /> Signature: <br />