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M <br /> r- 11yl, 5 &iX`•rF+AK ''fiw"t rr y+I,F�: ..+' r - � r4 <br /> p F <br /> IS <br /> 13alsr h.�fl- 'l� <br /> --~ GROL1NDWAI'I:H PURGE AND SAMPLE FORM (cont.) <br /> WELL ,— <br /> PROJF-CT NAME: <br /> lo21/ti•19 PERSONNEL: T.�• M•id. k•L• <br /> PROJECT NUMBER: ---- <br /> SAMPLE DATA: <br /> TIME SAMPLED: --------- — <br /> pEPTN SAMPLED(It): fiat <br /> SAMPLING EQUIPMENT: -- <br /> COMMENTS: <br /> .. VOLuuC '.WippEO UFWE71 AHAtY.'•Is. .- <br /> SA1IM-E :.•.HO:OF COHiAIFitn FiCt4: .(1LLED llinu DITY COLOR CiWI[OF CUCIOUY 'RLWF3T,: Cq.11.fLiiTS <br /> Pf1E.,EF14AT1VC nLYM110H AT -C IYR7j (tAGT}IOPi-- <br /> }IA...-- CA17T/i1NL(YS _�;.lYf"E-: (nllul) <br /> L�04 mJ, 6a �es Te"J"s 87 <br /> Vo A <br /> PURGE WATER DISPOSAL NOTES: <br /> TOTAL.DISCHARGE <br /> DISPOSAL METHOD: SS m��oti -rum <br /> DRUM DESIGNATION(S)NOLUME: SEA L <br /> COMMENTS: �`C <br /> WELL HEAD CONDITIONS CHECKLIST(Circle YES or NO--it NO,add comments) <br /> WELL SECQRITY DEVICES OK(BOLLARDS,CHRISTY LID,CASING LID AND LOCK)?: 5P NO <br /> INSIDE OF WELL HEAD AND OUTER CASING DRY?: CSE NO <br /> WELL CASING OK?: NO <br /> COMMENTS: '' ✓)e— <br /> GENERAL <br /> WEATHER CONDITIONS: <br /> TEMPERATURE(specify°C!°F): <br /> PROBLEMS ENCOUNTERED DURING PURGING OR SAMPLING? llOytN- <br /> COMMENTS: <br /> c-c. Project Manager. �--- <br /> JoU File: <br /> Othor: <br /> AIf <br />