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DOULOS ENVIRONMENTAL, INC. SAMPLING INFORMATION SHEET <br /> Client Ultramar Sarnpltng Date <br /> Site Beacon #3641 Project No <br /> 1210 E Hammer Lane1400 Well Designation <br /> Stockton Ca <br /> Is setup of traffic control devices required" YES time hours <br /> Is there standing water in the well box9 YES Above TOC Below TOC <br /> Is top of casing cut levelh NO YES If no, see remarks <br /> Is well cap sealed and lockedv r NO YES If no, see remarks <br /> Height of well casing riser(in inches) <br /> Well cover type 8"or 12" UV 12" EMCO 8"or 12"BK 8"Christy <br /> 12"Christy8"M&D 12"M&D 12"DWP <br /> 12"CNI 36" CNI 12"Pomeco Other /_---- -<7- <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 Centnfugal pump <br /> Sampled with Disposable bailer '" Teflon bailer Disposable Tubing <br /> Well Diameter 2" 4" 6" 811 <br /> Purge Vol Multiplier 0 16 065 1 47 2 61 gal/ft <br /> Initial Measurement Recharge Measurement <br /> Time _ Time ~- - " Calculated purge - <br /> Depth of well - t - / Depth to water v Actual purge v <br /> Depth to water c _ <br /> Startp urge 2Sampling time % <br /> Time Tem erature E C nU Turbiditv Volume <br /> r <br /> Sample appearance Lock 1 C <br /> Equipment replaced (check all that apply) Note condition of replaced item(s) <br /> 2" Locking Cap Lock 7132 Allenhead <br /> 4" Locking Cap Luck-Dolphin 9/16 Bolt <br /> 6"Locking Cap Pinned Allenhead (DWP) <br /> Remarks � <br /> Signature <br />