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'�' s-,4...ss:,.w.-r.rE vhy._.«�p�i(.-�r°i'�'^"ir`:a.:e.-... Sw�y.Nu+asi. i.-....+-- ,,. .a,.c-4:�•.e e,4.s�` <br /> - - -- <br /> SAMPLING INFORMATION SHEET <br /> Client - <br /> Sampling Date � ' 2.4 <br /> Site Project No <br /> Well Designation A-tw. <br /> caz <br /> Is setup of traffic control devices required? N YES time hours <br /> is there standing water in the well box9 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"or 12"W 12"EMCO 8"or 12"BK 8"Christy <br /> 12"Christy 8"M&D la ` 12"M&D 12"DWP <br /> 12"CNI 36"CNI 12"Pomeco Other <br /> General condition of wellhead assembly Excellent Good_ Fair Poor <br /> Purging Equipment 2"disposable bailer Submersible pump r <br /> 2"PVC bailer Dedicated bailer <br /> 4"PVC bailer Centnfugal pump <br /> Sampled with Disposable bailer Teflon bailer Disposable Tubing <br /> Well Diameter 2"_ '� 4" 6" $ • <br /> Purge Vol Multiplier 0 16 065 1 47 2 61 gaUR <br /> Initial Measurement Recharge Measurement <br /> Time -4"'] <br /> eTime /10 Calculated purge ! s <br /> epth of ll Depth to water Actual purge <br /> epth to water 3 Q <br /> ' Start purge ✓ Z Sampling time <br /> Time Temperature E C H Turbidit Volume <br /> 1211-S 1 /00 1 2- <br /> Sample appearance e� Lack 0 4.-" <br /> r <br /> Equipment replaced (check all that apply) Note condition of replaced item(s) <br /> 2" Locking Cap Lock 7/32 Allenhead <br /> 4" Locking Cap Lock-Dolphin9116 Bolt <br /> 6" Locking Cap Pinned Allenhead (DWP) <br /> marks - C <br /> w <br /> Signature <br />