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Groundwater Purge and Sample Form Date � / <br /> PROJECT NAME. Z-Z %e_r,ld WELL NUMBER. <br /> PROJECT NUMBER: PERSONNEL: �7�'}r^►^f� ✓C �`� ►tisC�� �`� <br /> SAMPLE DATA <br /> TIME SAMPLED I S5 COMMENTS <br /> aEPTH-SAMPLED-(FT)_ 3 <br /> SAMPLING EQUIPMENT: iS OSc-A�:_ C C" - - -- - -- - - - -- - - - -- - - - ' <br /> I <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 TORY AT 4°C? (METHOD) COMMENTS <br /> ot0 <br /> MW 3 q VOA 40_ r� w,,,i_ `--- lc�. '(,G LOIS 'T 5 <br /> �r <br /> PURGE WATER DISPOSAL NOTES. <br /> TOTAL DISCHARGE-(GAL). I S r� COMMENTS• �— <br /> DISPOSAL METHOD. r�d4 e_ r.. <br /> DRUM DESIGNATIONS)/VOLUME PER (GAL). <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;1NO <br /> INSIDE OF WELL HEAD AND OUTER CASING DRY?. ( y NO <br /> WELL CASING OK? Yj NO <br /> COMMENTS <br /> GENERAL <br /> WEATHER CONDITIONS- <br /> TEMPERATURE (SPECIFY °C OR <br /> PROBLEMS ENCOUNTERED DURING PURGING OR SAMPLING? ill D <br /> M Project Manager _4� k <br /> Job File <br /> Other <br /> F 43 2(5 as) Page 2 of 2 <br /> i <br />