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DOULOS ENVIRONMENTAL COMPANY <br /> SAMPLING INFORMATION SHEET <br /> Sampling Date <br /> Client: <br /> "Site: Project No. : <br /> w-47 -o <br /> 3 Q Ai Well Designation: <br /> Is setup of traffic control devices required? YES time: hours <br /> Is there standing water in well box? YES Above TOC Below TOC <br /> If no, see remarks <br /> Is tap of casing cut level? NO If no, see remarks <br /> Is well cap sealed and locked? <br /> Height of well casing riser (in 1inches) : 12" EMCO_ - 811 BK <br /> Well cover type: 8" W CNI X _ „ Other <br /> 12" BK 12" DWP Y2' 1 IN- <br /> $ 36 CNI_ oo Fair poor <br /> General condition of wellheadf assembly: Excellent <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,fa"- <br /> 0. 65 1. 47 2 . 61 gal/ft. <br /> Purge Vol. Multiplier: 0' 16 Rechar a Measurement <br /> . Initial Measurement Calculated purge: <br /> Time: 71Time: � �F <br /> Depth of well• 8'e,46 Depth to water: 6 6�"3 Actual purge: <br /> Depth to water:_ 613!? <br /> Start purge:_ « Sampling time:_ <br /> Time Temp. E.C. pH Turbidity Volume <br /> 9 2I 706 7� <br /> 6 g'3 M 69 <br /> 2� 6 C l 3 <br /> 9� 3 <br /> 15 9.;L <br /> Sample appearance: c .w Lock: �- <br /> Equipment replaced: (Check all that apply) Note condi tion <br /> of replaced item <br /> 2" Locking Cap: Lock #3753 : / <br /> 32 Allenhead: <br /> „ Lock-Dolphin: 9/16 Bolt: <br /> 4 Locking Cap: Pinned Allenhead (DWP) : <br /> 6" Locking Cap: <br /> Remarks: <br /> Signature: ' <br />