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Groundwater Purge and Sample Form Datef�Lj <br /> PROJECT NAME -z S f-r-v G IW c.►n WELL NUMBER ``k"\%,-/- y _ <br /> PROJECT NUMBER. PERSONNEL: f7''7CA <br /> SAMPLE E DATA: <br /> TIME SAMPLED I o, COMMENTS: <br /> DEPTH-SAMPLED-(FT): <br /> SAMPLING EQUIPMENT: - - - -- - <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 /> C116 _r- <br /> v,/-`4 UA- `-' y4,4, - 0r `l c s ►5 <br /> PURGE WATER DISPOSAL NOTES. <br />— —TOTAL-DISCHARGE-(GAL) V-< 11 _ COMMENTS �— <br /> DISPOSAL METHOD -Ory f- <br /> DRUM DESIGNATION(S)IVOLUME 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)?. NO <br /> INSIDE OF WELL HEAD AND OUTER CASING DRY?. -IffS' NO <br /> WELL CASING OK?: (YEP NO <br /> COMMENTS. <br /> GENERAL <br /> WEATHER CONDITIONS: Cttrc- <br /> TEMPERATURE (SPECIFY °C OR <br /> PROBLEMS ENCOUNTERED DURING PURGING OR SAMPLING? <br /> Cc Praj ect Manager C�c, + C c,�.✓` n f^ <br /> Job File <br /> Other <br /> F 43 2(5 69) Page 2 of 2 <br />