DGSI. Durham Geo Slope Indicator

Remediation Site Assessment Form

Printable Version

Complete as much information as possible and click on the submit button. Your request will be reviewed by one of Durham Geo's Technical Support Members and you will be contacted and provided with a site solution.

CUSTOMER INFORMATION
Company:						Date:
Contact:						Phone:
E-Mail:						Fax:
Title:
Address:
City:
State:	Select your State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Other-Use Note Field
Zip Code:
SITE INFORMATION
Site Location:
Job Reference #:
RECOVERY METHOD
Click to Select Total Fluids Dissolved Leachate Gas Condensate LNAPL DNAPL Dual Pump	Other:
WELL INFORMATION
Number of Wells:	1 2 3 4  If site has more than 4 wells Complete this section on another form and submit it.
Well Identification:					Brief Description of Each Well Location
Well Diameter (ID):					Specify in. or cm.
Total Well Depth:					Specify ft. or m.
Product/Water Depth:					Specify ft. or m.
Product Thickness:					Specify in. or cm.
Water Table Rise/Fall					Specify ft. or m.
Seasonal / Tidal:	Select S T	Select S T	Select S T	Select S T	Water table changes due to Seasons or Tides
PRODUCT INFORMATION
Type of Product:					Brief Description of Product
Product Viscosity:					Enter Viscosity of Product Present
Discharge Head:
Expected Flow Rate:					Enter Numeric and Select Rate Below
Gallons Per D/H/M	Select GPD GPH GPM	Select GPD GPH GPM	Select GPD GPH GPM	Select GPD GPH GPM	Select Rate of Removal gallons per Day/Hour/Minute
AIR INFORMATION
Distance to Air Source:					Enter the Distance the Air Source
Air Supply Line (ID):					Enter the Air Supply Line ID
Discharge Hose (ID):					Enter the Discharge Line ID
Recovery Tank:					Enter Approx. Distance to Product Recovery Tank
Air Compressor (SCFM):
Filtration on Compressor:	Yes No
Special Site Conditions:
Bidding Phase:
Site Plan Available:	Yes No
Delivery Date Required:

Complete as much information as possible and click on the submit button. Your request will be reviewed by one of Durham Geo's Technical Support Members and you will be contacted and provided with a site solution.