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DOQLOS ENVIRONMENTAL COMPANY SAMPLING INFORMATION SHEET <br /> Client: _ Sampling Date: <br /> Site: , cx}1 Project No. : <br /> l'1 Se- , Well Designation: <br /> I CA <br /> Is setup of traffic control devices required? O YES time: hours <br /> Is there standing water in well box? YES Above TOC Below TOC <br /> Is top of casing cut level? 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" W12" 12" EMCO 8" BK <br /> 12" BK 12" DWPt}�CNI 36" CNI Other <br /> General condition of wellhead absembly: Excellent 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: <br /> Well Diameter: 2" 4" 6" 8" <br /> Purge Vol . Multiplier: 0. 16 0. 65 1.. 47 2 . 61 gal/ft. <br /> Initial Jjeasur%Ment Rechargq <br /> Time: Time: Calculated purge:�� <br /> Depth of well : T �s Depth to water; � t �C� Actual purge: - - -3 <br /> Depth to water: <br /> Start purge: b'© I Sampling time: <br /> Time Temp. E.C. pH Turbidity Volume <br /> • <br /> OL <br /> 19 7 •B y �� 3 <br /> Sample appearance; Lock: <br /> Equipment replaced: (Check all that apply) Note condition of replaced item <br /> 2" Locking Cap; Lock , 3753 : 7/32 Allenhead: <br /> 4" Locking Cap: Lock-Dolphin: 9/16 Bolt: <br /> 6" Locking Cap; Pinned Allenhead (DWP) : <br /> Remarks : <br /> Signature: <br />