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' SAMPLING INFORMATION SHEET <br /> Client_ Ole m.�J;_�_ Sampling Date <br /> Site Protect No <br /> - --� Well Designation <br /> rIL <br /> ' Is setup of traffic control devices rcquireV YES time hours <br /> Is there standing water in the well box? S Above TOC Below TOC <br /> Is top of casing cut level? If no,see remarks <br /> ]s 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 MCO 8"or 12"BK 8"Christy <br /> 12"Christy 8"M&D 12"M&D 12"DWP <br /> 12"CNI 36"ChIY 12"Potneco Other ZZ^—""— <br /> ' General condition of wellhead assembly Excellent Good Pau <br /> Poor <br /> Purging Equipment 2"disposable bailer <br /> -- Submersi Ie pump <br /> 2"PVC bailer -Dedicated bailer <br /> PVC bailer <br /> Sampled with Disposable bailer Teflon bailer Centnfug 1 pump <br /> Disposable Tubing --� <br /> Well Diameter 2" 4" 6" _ <br /> _ 8» <br /> Purge Vol Multiplier; 0 16 065 147 <br /> 17 2' Initial Measurement Re har a easurement 61 gal/ft <br /> Time Time. $�3 <br /> Depth of well Z Calculated purge d r <br /> Depth to water; Z Actual purge. <br /> Depth to water ! <br /> FS <br /> Start purge _ c�� Sampling time <br /> Time Tem erature E C H <br /> T bidi glume <br /> , I ; <br /> . � i Y5 f , <br /> i <br /> Sample appearance OGt Oift- Lock: <br /> Equipment replaced (check all that app I <br /> 2"Lockin Ca Y) Note condition of laced item( <br /> g P Lock 7/32 Alle ead <br /> ' 4" Locking Cap Lock-Dolphin 9/16 Bolt <br /> 6"Locking Cap _ _ Pinned AIlenhead ( WP)- <br /> Remarks ,1 <br /> Signature <br /> r <br />