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Groundwater Purge and Sample Form Date 9,-3o- Kennedy/Jenks/Chilton <br /> PROJECT NAME: C'.t, Fa, riYA WELL NUMBER- <br /> PROJECT NUMBER: ''l��5 4U dU PERSONNEL. j�-3 <br /> 1 <br /> SAMPLE A• , _} /r <br /> TIME SAMPLED ��' �N1 COMMENTSyV�IC et)l I-CD <br /> DEPTH SAMPLED (FT) <br /> -� 7 <br /> SAMPLING EQUIPMENT: y_�S� ta�fC �� <br /> NO OF CON- FIELD VOLUME SHIPPED UNDER ANALYSIS <br /> SAMPLE CONTAIN- TAINER PRESER- FILTRA- FILLED CHAIN-OF-CUS- REQUEST <br /> NO ERS TYPE VATIVE TION (ml or L) TURBIDITY COLOR TODY AT 4°C? (METHOD) COMMENTS <br /> PURGE WATER DISPOSAL NOTES• <br /> TOTAL DISCHARGE (GAL)- JS J COMMENTS ttLc, <br /> DISPOSAL METHOD <br /> DRUM DESIGNATION(S)IVOLUME PER (GAL) G[GLr� -1S�L� <br /> WELL HEAD CONDITIONS CHECKLIST CIRCLE YES OR NO - IF NO ADD COMMENTS <br /> WELL SECURITY DEVICES OK (BOLLARDS, CHRISTY LID,�ASING LID AND LOCK) YES NO <br /> INSIDE OF WELL HEAD AND OUTER CASING DRY?• YE NO <br /> WELL CASING OK? YES <br /> COMMENTS �XAOOY Col?/Ut)jp2 <br /> GENERAL- <br /> WEATHER WEATHER CONDITIONS V 51.E h n <br /> TEMPERATURE (SPECIFY 'C OR °F) <br /> PROBLEMS ENCOUNTERED DURING PURGING OR SAMPLING? 11 ky 5AL42)� AIZ44L— <br /> c- Project Manager. <br /> Job File <br /> Other <br /> F 43 2(4 88) Page 2 of 2 <br /> I <br />