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Groundwater Purge and Sample Form Date <br /> PROJECT NAME. z '��c ri^e- t` kk -,C� C C< WELL NUMBER.�./m%^J- -7 `wY, <br /> PROJECT NUMBER- PERSONNEL: 41 C, � .r I v,-,- f <br /> SAMPLE DATA <br /> TIME SAMPLED COMMENTS. <br />—-DEPTH-SAMPLED-(FT--)• d� _ - - - - -_ <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 49C? (METHOD) COMMENTS <br /> M\./L1 W VLA ►...L ji� 'Y-e 5 k,0/5 5 <br /> PURGE WATER DISPOSAL ?TOTES. <br /> -TOTAL-DISCHARGE-(GAL:): 6- -a, COMMENTS: - <br /> DISPOSAL METHOD <br /> DRUM DES IGNATION(S)NOLUME 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)?. fE NO <br /> INSIDE OF WELL HEAD AND OUTER CASING DRY?: NO <br /> WELL CASING OK7 yrs NO <br /> COMMENTS <br /> GENERAL. <br /> WEATHER CONDITIONS• 0-e <br /> TEMPERATURE (SPECIFY -C OR C)) <br /> PROBLEMS ENCOUNTERED DURING PURGING OR SAMPLING? <br /> cc, Project Manager. U JF,N <br /> Job File �- <br /> Other. <br /> F 43 2(5 89) Page 2 of 2 <br />