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1 <br /> DOULOS BNVIRON�ENTJL Comp"y - SAMPLING INFORMATION SHEET <br /> Client: Sampling Date: <br /> Site: r <br /> 1 �_ Project No. ; <br /> /,1�6 00 tt' oj=/an LZ Well Designation: j <br /> Is setup of traffic control devices required? YES time: hours <br /> 1 Is there standing water in well box? cov YE 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" W 12" UV12" EMCO 8" BK <br /> 12" BK 1211 DWP 12" CNI_ 36" CNI Other R- I <br /> General condition of wellhead assembly: Excellent oo Fair Poor <br /> Purging Equipment: 2" disposable bailer Submersible pump <br /> 21' PVC bailer Dedicated bailer <br /> 4" PVC bailer Centrifugal pump <br /> 1 Sampled with: Disposable bailer: Teflon bailer: <br /> Well Diameter: 2"ten 4" 6" Bit- <br /> Purge <br /> "Purge Vol . Multiplier: 0. 16 0. 65 1. 47 2 . 61 gal/ft. <br /> ANkInitial Measurement (U� <br /> ime: Time: 0= O Calculated purge: L <br /> Depth of well : Depth to water: O Actual purge. <br /> Depth to water: <br /> Start purge: 0I Sampling time: ? <br /> Time <br /> ' Temp.. . E. C. pH Turbidity Volume <br /> O <br /> 1/0 -. 0 cc) <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: 9/1.6 Bolt:� ' <br /> 611 Locking Cap: Pinned Al lenhead (DWP <br /> Ii .nom■ i�ini� ..w—a ri�r� <br /> . Remarks : <br /> Signature : <br />