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DOULOS ENVIRONMENTAL COMPANY SAMPLING INFORMATION SHEET <br /> Client: Ultramar Samphng Date y-A 7`q-5 --- <br /> Site Beacon#695 Project No 94695-01 <br /> 2M SQA Clwokgg Lne Well Desipaimn MW- a g <br /> Lode.CA <br /> la setup of traffic control devices required' YES time hours <br /> Is there standing water in well box? YES Above TOC Below TOC <br /> la top of casing out level? NO If no,see remarkn <br /> Is well cap sealed and locked? NO If no,we remarkn <br /> Height of well casing riser(in mchea) <br /> Well cover type 8"UV 12"UV 12"EMCO S" BK <br /> l2"BK 12"DPW 12" CNi 36"CNI Other <br /> General condition of wellhead assembly Excellent Fair Poor <br /> Purging Equipment 2"disposable bailer Submersible pump <br /> 3"PVC bailer Dedicated bailer <br /> 4"PVC bailer _Centnfugal pump <br /> Sampled with Disposable bailer — Teflon bailer <br /> Well diameter r 4" 6A an <br /> Purge Vol.Multiplier 016 063 147 2.61 gal/R <br /> lnrtral Measureineni B.4chm Measui <br /> iTime /.t .... Time L4 19 CaUmlated purer <br /> Depth of well 7�S_K Depth to watch Ach"purge -6— <br /> Depth to C!Z 9 <br /> Stmt Purge Sampling time <br /> Tune Tempeeratm E. C pH Turbidity Vohime <br /> 4115 a 7a.a <br /> Sample appearance Lock <br /> Equipment replace& (Che&all that apply) Note oauditi m of replaced item <br /> 2"locking cap Look 03753 7/32 Allenhead <br /> 4"locking cap Leak-Dolphin 9/16 bolt <br /> 6"locking cap Perused All d(DPW) <br /> Remarka <br /> Signature <br />