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' GROUNDWATER PURGE AND SAMPLE FORM (cont_) Date 7 <br /> PROJECT NAME 7'3T,�FWELL NUMBER: W( 7 <br /> PROJECT NUMBER �y� �� PERSONNEL: w <br /> SAMPLE DATA- <br /> TIME SAMPLED 1 <br /> DEPTH SAMPLED (ft) <br />' SAMPLING EQUIPMENT <br /> COMMENTS .rte <br /> SAMPLE NO OF CONTAINERVOLUME S"PPEDUNDER ANALYSIS <br /> FID. CONTAINERS TYPE PRESERVATIVE F; FIELD <br /> ]ON FILLED TURBIDITY COLOR CHAIN OF CUSTODY REQUEST COFAi�{EN'('$ <br /> {mI or q AT 1'C(Y" (METHOD) <br /> 3 �IQ2� ItG L 'VIA- �5 <br /> D6 y <br /> rE <br /> PURGE WATER DISPOSAL NOTES <br /> TOTAL DISCHARGE (gal) 3 <br /> DISPOSAL METHOD <br /> DRUM DESIGNATION(S)/VOLUME S/X <br /> COMMENTS <br />' gZQegfC- <br /> WELL HEAD CONDITIONS CHECKLIST (Circle YES or NO-- if NO, add comments) <br /> WELL SECURITY DEVICES OK (BOLLARDS, CHRISTY LID,CASING LID AND LOCK)? S NO <br /> INSIDE OF WELL HEAD ANQ UTER CASING DRY? YES O fE <br /> WELL CASING OK?,�ES O <br /> COMMENTS <br /> GENERAL <br /> WEATHER CONDITIONS <br /> TEMPERATURE (specify 000F) D4 <br /> PROBLEMS ENCOUNTERED DURING PURGING OR SAMPLING? <br /> COMMENTS <br /> c_c Project Manager <br /> Job File <br /> Other <br /> I <br />