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5 <br /> DOULOS ENVIRONMENTAL, INC. SAMPLING INFORMATION SHEET <br /> Client Ultramar Sampling Date / �•?G'� Z- <br /> Site Beacon #3641 Project No <br /> 1210 E Hammer Lane 1400 Well Designation /`!t(/✓`� <br /> Stockton,Ca <br /> Es setup of traffic control devices required YES time hours <br /> Is there standing water in the well boxy Y S Above TOC Below TOC <br /> Is top of casing cut level? 0 If no, see remarks <br /> Is well cap sealed and locked? NO E If no, see remarks <br /> Height of well casing user(in inches) 3 <br /> Well cover type 8" or 12"UV 12"EMCO 8"or 12" BK 8" Chnsry <br /> 12" Chnsry 8"M&D 12"M&D 12"DWP <br /> 12" CNI 36" CNI 12" Pomeco Other !2s, ^ <br /> General condition of wellhead assembly ExcelIent 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 .gy� Teflon bailer Disposable Tubing <br /> Well Diameter 2" _ 4" 6" 8" <br /> Purge Vol Multiplier 0 16 065 1 47 2 61 gal./ft <br /> Initial Measurement Recharge Measurement <br /> Time /0 :20 Time Calculated purge Lr Q <br /> Depth of well s$'./ Depth to water Actual purge <br /> Depth to water G <br /> Startur e // <br /> p g /f Sampling time '21-16 <br /> Time Temperature E G pH Turbidity Volume <br /> 63�5- <br /> Sample appearance - Lock /V <br /> Equipment replaced (check all that apply) Note condition of replaced item(s) <br /> 2" Locking Cap Lock 7132 Allenhead <br /> 4" Locking Cap Lock-Dolphin 9/16 Bolt <br /> 6" Locking Cap Pinned Allenhead (DWP) <br /> Remarks <br /> � • l � <br /> S ignature <br /> I <br />