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-Ssf^ti ,,4sg..yb.e.:ry.•..sr�p�tcr.�.s.�s�..�� +a w�.wIn��'ht+3.ahw r. ��r ,- .- � v7.en5xf�hi1+F� <br /> a <br /> rSAMPLING INFORMATION SHEET <br /> Client16 Sarripling Date 2 z'0-3 <br /> Site W 21 Project No <br /> Well Designation <br /> 1 <br /> Is setup of traffic control devices required9 YES time hours <br /> Is there standing water in the well boxy US Above TOC Below TOC <br /> Is top of casing cut level? NO If no, see remarks <br /> ' Is well cap sealed and locked? / NO ES If no,see remarks <br /> 6 <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 12"M&D 12"DWP <br /> 12"CNI 36"CNI 12"Pomeco Other$I"t b t't'7 <br /> General condition of wellhead assembly Excellent Good 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 Disposable bailer C- Teflon bailer Disposable Tuning <br /> Well Diameter 2" - 4" 6" 831 <br /> Purge Vol Multiplier 016 065 1 47 2 61 gal/ft <br /> Initial Measurement Recharge Measurement <br /> Time :00 Time l• �� Calculated purge �• <br /> epth of well Depth to water Actual purge Q <br /> epth to water Z , <br /> Start purge �� Sampling time <br /> TimeTem erature E C fH Turbidit Volume <br /> :C) X0 . 6 f <br /> 1 <br /> Sample appearance Lock2OL—A—py-- <br /> Equipment <br /> replaced (check all that apply) Note condition of replaced item(s) <br /> 2" Locking Cap Lock 7/32 Allenhead <br /> 4" Locking Cap Lock,Dolphin 9/P6 Bolt <br /> 6" Locking Cap Pinned Allenhead (DWP) <br /> I- <br /> marks <br /> 6 <br /> l <br /> r <br /> Signature , <br />