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' GROUNDWATER PURGE AND SAMPLE FORMcpn Date <br /> PROJECT NAME L �-� { t.) <br /> WELL NUMBER �,3 <br /> PROJECT NUMBER-Z _ PERSONNEL- 141— Lt-4z4.-- <br /> 1SAMPLE DATA: <br /> TIME SAMPLED <br /> DEPTH SAMPLED (ft) <br />' SAMPLING EQUIPMENT ,fir <br /> COMMENTS <br /> SAMPLE NO of CONTAINER FIEW VOLUME SFIIPPEOUNOEIi <br /> N0. CONTAINERS TYPE PRESERVATIVE FILLED TUR84EXTY COLOR ANALYSIS ' <br /> FILTRATION CHAIN OF GUSWay REQUEST C01AiAENTS <br /> AT 4-C(YIN] (METHOD) <br /> T <br /> 1 <br />' Ph <br /> PURGE WATER DISPOSAL NOTES- <br /> TOTAL DISCHARGE (gal) <br /> DISPOSAL METHOD <br /> DRUM DES IGNATION(S)IVOLUME 1-,05X <br /> COMMENTS <br /> 1 <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)- YES 6D <br /> INSIDE OF WELL HEAD AND OUTER CASING DRY-7 YES <br /> WELL CASING OK? TLS' NO <br /> COMMENTS LvA2"7 <br /> GENERAL <br /> WEATHER CONDITIONS <br /> TEMPERATURE (specify oCrF) m� <br /> PROBLEMS ENCOUNTERED DURING PURGING OR SAMPLING? <br /> COMMENTS - <br /> -------------- <br /> cc Project Manager <br /> Job File <br /> Other <br />