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DOQL0S BNVIRONMSNTAL COKPANY SAMPLING INFORMATION SHEET <br /> Client: a Sampling Date:_ 2.I —9L� <br /> 1 <br /> Site: �'�'O�'�' `" ! Project No. : <br /> SOI \A/ JCC- IQW►A_ L'h'Fell Designation: <br /> 0( C_^ <br /> Is setup of traffic control devices required? N YES time: hours <br /> Is there standing water in well box? 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) - 3 <br /> Well cover type: 8" W 12" UV_ 12" EMCO 8" BK <br /> 12" BK 12" DWP 12" CNI 36" CNI ther <br /> General condition of wellhead assembly: Excellent *0 65 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: Disposal 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 Measurement Rechar a Measurement <br /> tme: -3 g q Time: Calculated purge: �CA <br /> `depth of well: Depth to water: Z- Actual purge: <br /> Depth to water: <br /> Start purge: I Sampling time: <br /> Time Temp. E.C. pH Turbidity Volume <br /> 31(53 7 � 2-- 7 -7 , &q-- <br /> -3 ('58 <br /> 7 , &q-3 ('5g ' Z � 0�— 71 5 Z. Z <br /> o 5 , Z 7 -7 t 4 s ---- <br /> � 7 -2- 7 , 7, 12-- <br /> Sample <br /> ,Sample appearance: Lock: <br /> Equipment replaced: (Check all that apply) Note condition of replaced item <br /> 2" Locking Cap: Lock 13753: 7/32 Allenhead: <br /> 4" Locking Cap: Lock-Dolphin: 9/16 Bolt: <br /> 6" Locking Cap: Pinned Allenhead (DWP) : <br /> Remarks: <br /> Signature: �/ / <br />