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DOULOS ENVIRONMENTAL COMPANY SAMPLING INFORMATION SHEET <br /> Client - Ultramar Sampling Date: '- l°1 <br /> Sate: Beacon #695 Pro]ect No. : 94-695-01 , <br /> 900 S . Cherokee Lane Well Designation:_ MW_ _ <br /> Lodz CA <br /> Is setup of traffic control devices required' YES time: hours <br /> Is there standing water an well box' oo Y,ES 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 If no, see remarks <br /> Height of well casing riser ( in inches) : ' <br /> Well cover type: 8" UV 12" UV12" EMCO 8" BY <br /> 1211 BK 1211 DWP 1211 CNI V 3611 CNICher <br /> General condition of wellhead assembly: Excellent Goo 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: Disposal bailer: Teflon bailer: <br /> Well Diameter: 2 f"'All 41" 6" <br /> T <br /> Purge Vol . Multiplier: 0 . 1.6 0 . 65 1 . 47 2 . 61 gal/ft. <br /> Initial Measurement Recharcte Measurement <br /> Time: /� Time:_ i .f Calculated purge: <br /> Depth of well: :yl�' Depth to water: 4G 75 Actual purge: R <br /> Depth to water• ;4q' <br /> Start purge: Sampling time: 5 3;� <br /> Time Temp. E. C. pH Turbidity volume <br /> Sample appearance: Lock: -'�- -� <br /> Equipment replaced. (Check all that apply) Note condition of replaced item <br /> 2'" Locking Cap: Lock #3753 : 7/32 Allenhead: <br /> 4" Locking Cap: Lock-Dolphin: 9/16 Bolt: <br /> 6" Locking Cap: Pinned Allenhead (DWP) : <br /> Remarks: <br /> Signature: <br /> J 1 <br />