NDEQ PROGRAM: | Fill in the name of the NDEQ program for which the sample was taken. |
PROJECT NAME: | Fill in the name of the project for which the sample was taken. |
Resource Tracking #: | Fill in the two-digit program number, three-digit subprogram number, and four-digit project number |
Sample Collector: | Fill in the name of the person(s) who collected the sample. |
Send Results To: | Fill in the name of the person to whom the analytical results should be sent. |
FACILITY/SITE/TRIP NUMBER: | Fill in the number of the facility/site OR the trip (not both), if applicable. This typically consists of a facility or site identification number OR an NDEQ identification number and departure date (mm/dd/yy). |
Activity No.
Sample No.
QC ID Number
| Fill in the appropriate activity, sample, or quality control (QC) identification number. This will typically be specified according to the individual project or program. |
Location Description | Fill in the description of the location at which the sample was taken. This will typically be a description of the point from which the sample was taken (e.g. Discharge Pipe, Monitoring Well #1, etc.) or a landowner’s name. |
Collection Date | Fill in the date on which the sample was collected. |
Collection Time | Fill in the time at which the sample was collected. Use military time; e.g. 8:15 AM will be 0815; 1:45 PM will be 1345. |
Lab Numbers | Fill in the laboratory number(s) for the particular sample. THIS WILL TYPICALLY BE FILLED IN BY LABORATORY PERSONNEL. |
Number of Containers | Fill in the number of containers making up each sample. |
PARAMETER REQUEST |
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Physical | Check the appropriate box or boxes if you wish to have laboratory analysis for pH, conductivity, total suspended solids, total dissolved solids, or hardness. |
Nutrients | Check the appropriate box or boxes if you wish to have laboratory analysis for ammonia, nitrate-nitrite, total Kjeldahl nitrogen, phosphate, or dissolved orthophosphate. |
Trace Minerals | Check the appropriate box or boxes if you wish to have laboratory analysis for chloride, sulfate, sodium, magnesium, calcium, potassium, or alkalinity. |
Microbiological | Check the appropriate box or boxes if you wish to have laboratory analysis for fecal coliform or fecal streptococcus bacteria. |
Demands | Check the appropriate box or boxes if you wish to have laboratory analysis for biological oxygen demand, chemical oxygen demand, or total organic carbon. |
Metals | Check the appropriate box or boxes if you wish to have laboratory analysis for arsenic, chromium, lead, selenium, cadmium, chromium (hexavalent), mercury, silver, copper, iron, nickel, or zinc |
(Total Dissolved check) | Check whichever item is appropriate; total infers that the samples have not been or will not be filtered, while dissolved implies samples have been or need to be filtered. |
OTHER (list method): | List any other analyses which you need. Before requesting such analyses, be sure that the laboratory has the ability to provide them. |
COMMENTS (Optional): | Provide any other comments which may be helpful, such as notes on sample condition, any irregularities in labeling or packaging, etc. |
Container/Preservation (Check) | Indicate the kind of container and preservation used for your samples. |
Un-preserved Cubie | Check if sample is provided in a 1 l polyethylene cubitainer without preservatives. |
Un-Pres. Glass
w/ Teflon Lid (Qt.)
| Check if sample is provided in a 1 quart glass jar with Teflon lid and without preservatives. |
Filtered/Un-Pres. | Check if sample has been filtered but no preservatives have been added. |
Cubie/H2SO4 | Check if sample is provided in a 1 l polyethylene cubitainer and preserved with concentrated sulfuric acid. |
Pres. (H2SO4-) Glass
w/ Teflon Lid (Qt.)
| Check if sample is provided in a 1 quart glass jar with Teflon lid and preserved with concentrated sulfuric acid. |
Filtered/Pres. (H2SO4) | Check if sample has been filtered and preserved with concentrated sulfuric acid. |
Cubie/HNO3 | Check if sample is provided in a 1 l polyethylene cubitainer and preserved with concentrated nitric acid. |
Filtered/Pres. (HNO3) | Check if sample has been filtered and preserved with concentrated nitric acid. |
Un-Pres./No Air Space | Check if sample is unpreserved and has been filled to the exclusion of air. |
Other (Specify) | Check and specify if a container and/or means of preservation has been employed other than those listed. |
Total Number of Samples | Enter the total number of samples included with this particular form. |
TYPE OF SAMPLE (check) | Check the appropriate box for the type of sample provided. This information is optional. |
Influent | Check if the sample represents water flowing into a particular sampling point and used to document a certain process. |
Effluent | Check if the sample represents water flowing out of a particular sampling point and used to document a certain process. |
Grab | Check if the sample represents water taken at an unspecified sampling point and used to document general conditions. |
Composite | Check if the sample represents a composite or combination of several sub-samples. |
Field Blank | Check if the sample was prepared in the field from deionized water. |
Ground Water (mon, irrig, dom, PWS, other) | Check if the sample is a ground water sample taken from a monitoring, irrigation, domestic, public water supply, or other type of well. |
Surface Water | Check if the sample is a surface water sample taken from a stream, lake, etc. |
Soil | Check if the sample is a soil sample. |
Waste | Check if the sample is a type of waste. |
Other | Check if the sample is some other medium. |
FIELD MEASUREMENTS | Enter the appropriate results of field measurements, if any were taken. These entries are optional. |
Flow (gal/day) | Enter the flow rate at which the water sample was taken, in gallons per day. |
Water Temp (º C) | Enter the temperature of the water sample, in degrees Centigrade. |
Diss. Oxygen (mg/l) | Enter the dissolved oxygen concentration, in milligrams per liter. |
pH (su) | Enter the pH, in standard units. |
Cond. (umho/cm) | Enter the specific conductance, in micromhos per centimeter |
Other | Enter any other field measurements taken. |
CHAIN OF CUSTODY RECORD | Record the individuals who have handled the samples, and the date(s) and time(s) at which this took place. |
Samples Delivered By | The individual(s) who delivered the samples must sign in this space. |
Samples | The individual(s) who received the samples must sign in this space. |
Date | Enter the date (month, day, and year) on which the samples were delivered. |
Time | Enter the time (military or AM/PM) at which the samples were delivered. |
Lab Numbers | The laboratory personnel must enter the lab number(s) of the samples in this space. |
Data Delivered By | The individual who delivered the analytical results must sign in this space. |
Data Received By | The individual who received the analytical results must sign in this space. |
Date | Enter the date (month, day, year) on which the data was delivered. |
Time | Enter the time (military or AM/PM) at which the data was delivered. |
Lab Numbers | The laboratory personnel must enter the lab number(s) of the data (if applicable) in this space. |
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NOTE: Numbers in brackets (e.g. {3}) denote columns for laboratory data entry forms. |
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