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Groundwater Purge and Sample Form Date A A <br /> PROJECT NAME „E 1 5,Crvv-, Mati�f- CK WELL NUMBER. <br /> PROJECT NUMBER: 'f"' PERSONNEL: 43( <br /> SAMPLE DATA <br /> TIME SAMPLED: _r 4�6 COMMENTS: <br /> DEPTH-SAMPLED-(FT). 02 <br /> - - SAMPLING EQUIPMENT bc,{I-P_ r- -- - ------ --- - -- -- — – - - <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 (m1 or L) TURBIDITY COLOR TODY AT 40C? (METHOD) COMMENTS <br /> VDA, 4- G1_ moi.. ---_ !� ✓ t r s <br /> PURGE WATER DISPOSAL NOTES: <br /> —TOTAti DISCHARGE-(GAL): al , COMMENTS v— <br /> DISPOSAL METHOD. <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)? NO <br /> INSIDE OF WELL HEAD AND OUTER CASING DRY?. !�3 NO <br /> WELL CASING OK?: !P NO <br /> COMMENTS <br /> GENERAL. <br /> WEATHER CONDITIONS ex r- <br /> TEMPERATURE (SPECIFY -C OR(i) 6 q _ <br /> PROBLEMS ENCOUNTERED DURING PURGING OR SAMPLING? Oy_ <br /> cc. Project Manager G, Cr.".' <br /> Job File - - <br /> Other. <br /> F 43 2(5 89) Page 2 of 2 <br />