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Facility Name Permittee County MSW Permit No. Name of Sampler Affiliation of sampler: Laboratory Site Operator's Signature: Monitor Well No. Integrity of Well Installation Date Most recent previous sampling Date of water level measurements Datum Reference point: Datum elevation: Well depth Depth to water Water Level elevation Sample Event (Purpose): Sample schedule: Sample type: Purging sample method: Where low-flow methods used? Date purged 1-well volume (gallons) Gallons purged Well Volumes Purged Was the well dry before purging? Was the well dry after purging? Date of sample collection How long before sampling (Days) pH: Specific conductivity (umho/cm) Temperature (C) Clarity