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1 <br /> 1 <br /> DOULOS ENVIRONMENTAL COMPANY SAMPLING INFORMATION SHEET <br /> Client: Sampling Date:__ <br /> • Site: Project No. : <br /> D <br /> / i6 Q 2 P0,41 Gin Rod Well Designation: <br /> R <br /> Is setup of traffic control devices required? YES time: hours <br /> 1 Is there standing water in well box? A=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" UV12" UV 121' EMCO 8" BK <br /> 1211 BK 1211 DWP 12" CNI 3611 CNI Other M o d-E- /, <br /> 1 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 /> 1 Sampled with: Disposable bailer:__)�,, Teflon bailer: <br /> Well Diameter: 2" 4" 6" sit- <br /> Purge <br /> "Purge Vol. Multiplier: 0. 16 0. 65 1. 47 2 . 61 gal/ft. <br /> AKnitial Measurem2nt Beq4grgeQ <br /> ime: Time: Calculated purge:_ y __ [ <br /> Depth of well : Q Depth to water: Actual purge _ <br /> Depth to water: <br /> Start purge: O Sampling time: 0 <br /> Time Temp. . E. C. pH Turbidity Volume <br /> 1/0 ! 2 , y3 / - ) L <br /> o� 72 e-t 7- � 2 <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 />