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DOULOS ENVIRONMENTAL, INC SAMPLING INFORMATION SHEET <br /> Client Ultramar Sampling Date • 6 ` <br /> . Site Beacon #3641 Project No <br /> 1210 E Hammer Lane 1400 Well Designation <br /> Stockton Ca <br /> Is setup of traffic control devices required9 KOC YES time hours <br /> Is there standing water in the well box9 YFk Above TOC Below TOC <br /> Is top of casing cut level? NO YES If no, see remarks <br /> Is well cap sealed and locked? NO YES" If no, see remart, <br /> Height of well casing riser(in inches) <br /> Well cover type 8"or 12"UV I2" EMCO 8" or 12"BK 8"Christi <br /> 12"Christy8"M&D 12"M&D 12"DWP <br /> 12"CNI -46" CNI - 12"Pomeco Other <br /> General condition of wellhead assembly Excellent Good - Fair Poor <br /> Purging Equipment 2" disposable bailer Submersible pump <br /> 2" PVC bailer Dedicated bailer <br /> 4" PVC bailer Centrifugal pump <br /> Sampled with Disposable bailer Teflon bailer Disposable Tubing <br /> Well Diameter 2" 4" 6" g" <br /> Purge Vol Multiplier 0 16 065 1 47 2 61 gal/ft <br /> Initial Measurement Recharge Measurement <br /> Time - ;4 Time -- - Calculated purge l% ^ —'IF <br /> Depth of well Depth to water "-- `- Actual purge <br /> Depth to water <br /> Start purge f 7� Sampling time + ? <br /> Time Temperature E C H Turbidit,- Volume <br /> � I � � � �' • � �" �� � 6 .61Q <br /> Sample appearance C &Clot Lock <br /> Equipment replaced (check all that apply) Note condition of replaced item(s) <br /> 2" Locking Cap Lock 7/32 Allenhead <br /> 4" Locking Cap Lock-Dolphin 9/16 Bolt <br /> 6" Locking Cap Pinned Allenhead (DWP) <br /> Remarks <br /> Signature <br />