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DOULOS ENVIRONMENTAL COMPANY <br /> SAMPLING INFORMATION SHEET <br /> Client• Sampling Date: <br /> • Prod ect No. <br /> - <br /> site:- <br /> Well Designation: <br /> Is setup of traffic control devices required"' ® YES time., hours <br /> Is there standing water in well box? (:OD YES Above TOC Below TOC NO ( If no, see remarks <br /> Is top of casing cut level? If no, see remarks <br /> Is well cap sealed and locked. N <br /> Height of well casing riser (in 1211�;Z 12„ EMCO $" BK <br /> Well cover type: 8" 36" CNI Other <br /> 12" BK 12" DWP 121+ CNI Excellent o Fair Poor <br /> General condition of wellhead assembly: <br /> 2++ disposable bailer �C- Submersible pump <br /> Purging Equipment. Dedicated bailer <br /> 2+' PVC bailer <br /> 4" PVC bailer Centrifugal pump <br /> Sampled with: Disposable bailer:_ Teflon bailer: <br /> Well Diameter: 211 419-- '^ 611 811 <br /> 0. 65 1. 47 2 . 61 gal/ft. <br /> Purge Vol. Multiplier: 0' 16 Bechar a Measurement <br /> Initial Measurement 0 Calculated purge• 6" �C <br /> Time: O Time: !O: . <br /> Depth of well: �7 � 9 Depth to water: <br /> q- Actual purge: (�.C�� c <br /> Depth to water: <br /> Start purge: <br /> �_� Sampling time: <br /> Time Temp. E.C. pH Turbidity Volume <br /> 3 C) <br /> 0 <br /> Sample appearance: <br /> Lock: <br /> Equipment replaced: (Check all that apply) Note condition of replaced item <br /> 2" Locking Ca Lock #3753 : 7/32 Allenhead:r� <br /> g P:------ 9/16 Bolt: <br /> 4" Locking Cap: <br /> Lack-Dalph�n: ^ <br /> 6" Locking Cap: Pinned Allenhead (DWP) :- - <br />. Remarks: <br /> r <br /> Signature: �� <br />