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Groundwater Purge and Sample Form Date .__ Kennedy/Jenks Consultants <br /> PROJECT NAME: WELL NUMBER.: <br /> PROJECT NUMBER: PERSONNEL: <br /> 1 <br /> SAMPLE DATA: <br /> TIME SAMPLED: COMMENTS: <br /> DEPTH SAMPLED (FT): <br /> SAMPLING EQUIPMENT: <br /> NO. OF CON- FIELD VOLUME SHIPPED UNDER ANALYSIS n <br /> SAMPLE COERSIN TYPE NATIVE- FTIONA (m1IorEL) TURBIDITY COLOR TODYNA�F4CC? REQUEST <br /> (METHOD) COMMENTS <br /> �J <br /> PURGE WATER DISPOSAL NOTES: <br /> TOTAL DISCHARGE (GAL): COMMENTS:- <br /> DISPOSAL METHOD: Li <br /> DRUM DESIGNATIONS)/VOLUME PER (GAL): iJ <br /> WELL HEAD CONDITIONS CHECKLIST (CIRCLE YES OR NO - IF NO, ADD COMMENTS): <br /> WELL SECURITY DEVICES OK (BOLLARDS, CHRISTY LID, CASING LID AND LOCK)?: YES NO <br /> INSIDE OF WELL HEAD AND OUTER CASING DRY?: YES NO <br /> WELL CASING OK?: YES NO <br /> COMMENTS: <br /> GENERAL: <br /> WEATHER CONDITIONS: F1 <br /> TEMPERATURE (SPECIFY °C OR °F): u <br /> PROBLEMS ENCOUNTERED DURING PURGING OR SAMPLING? I <br /> cc: Project Manager: jJ <br /> Job File: <br /> Other: ' <br /> 'r 432(5-89) Page 2 of 2 }J1 <br />