Form 24 - Soil Analysis Report Form
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FORM
FOR OGCC USE ONLY
24
State of Colorado
Rev 2/03
Oil and Gas Conservation Commission
1120 Lincoln Street, Suite 801, Denver, Colorado 80203 (303)894-2100 Fax:(303)894-2109
SOIL ANALYSIS REPORT FORM
Contact Name and Telephone:
OGCC Operator Number:__________________________
Complete the
Attachment Checklist
________________________________________
Name of Operator:_________________________________________
Oper OGCC
No:______________________________
Analysis
Address:_________________________________________________
Sample Location Map
Fax:_____________________________
City:___________________________ State:_____ Zip:___________
Source of Sample Collection:
SPILL
PIT
WELL
FLOWLINE
GAS PLANT
BATTERY
SAMPLE POINT INFORMATION
(Sample Location Map Must Be Attached)
Date Sample(s) Taken: _________________________
Sample Point Description: ____________________________________________________________________________________________________
If Well, API Number: ______________________ Well Name: ___________________________________________ Well Number: _________________
QtrQtr: _________________ Section: ________________ Township: _______________ Range: ________________ Meridian: _______________
Footage From Exterior Section Lines: ___________________________________________________________________________________________
Latitude: _________________________ Longitude: _______________________________ County: _______________________________________
Field Name: ______________________________________________________ Field Number: ____________________________________________
LABORATORY RESULTS
Initial Test Results
Interim Test Results
Final Test Results
Name of Laboratory: _______________________________________________________________ Phone: __________________________________
Matrix of Sample:
Soil
Water
Soil and Water
FIELD MEASUREMENTS
pH _____________________ pH unit
Electrical Conductivity _____________________________ mmhos/cm
Sodium Adsorption Ratio: ______________________________________
TDS: ___________________________________________ mg/kg
LABORATORY RESULTS
pH _____________________ pH unit
Electrical Conductivity _____________________________ mmhos/cm
Sodium Adsorption Ratio: ______________________________________
TDS: ___________________________________________ mg/kg
TPH (8015 modified): ________________ mg/kg
PID
FID
Hanby
Other (check one)
TRPH (418.1): _____________________ mg/kg
PID
FID
Hanby
Other
BTEX (METHOD 602)
Complete this section only if requested.
Benzene: _______________ ug/l
Ethylbenzene: _______________ ug/
Toluene: _______________ ug/
Xylenes: _______________ ug/l
TOTAL METALS
Complete this section only if requested.
Arsenic: ____________________ mg/kg
Barium: ____________________ mg/kg
Cadmium: ____________________ mg/kg
Chromium: __________________ mg/kg
Cyanide: ___________________ mg/kg
Fluoride: _____________________ mg/kg
Lead: ______________________ mg/kg
Mercury: ___________________ mg/kg
Selenium: ____________________ mg/kg
Silver: ______________________ mg/kg
Print Name: _________________________________________ Signed: ________________________________________
Title:__________________________________________ Date:_____________________
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