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DOULOS ENVIRONMENTAL, INC. SAMPLING INFORMATION SHEET <br /> Client Ultramar Sampling Date 12 - l 3 — 1 <br /> • Site Beacon 7 6 Project No <br /> Well Designation 1�w <br /> Is setup of traffic control devices required9 O YES time hours <br /> Is there standing water in the well box9 YES Above TOC Below TOC <br /> Is top of casing cut level9 NO If no, see remarks <br /> Is well cap sealed and Iocked9 NO If no, see remarks <br /> Height of well casing riser(m inches) 6 <br /> Well cover type 8" or 12"UV 12"EMCO 8"or 12"BK 8"Chnsty <br /> 12"Chnsty 8"M&D 12"M&D 12"DWP <br /> 12" CNI �&2I � 12" Pomeeo Other <br /> General condition of we clad assembly Excellent Goad 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"2-1 4" 6" 8" <br /> Purge Vol Multiplier 0 16 065 1 47 2 61 gal/ft <br /> Initial Measurement Recharge Measurement <br /> Time ?_ Time cl - 2 Calculated purge O <br /> Depth of well S tf S Depth to water 7 Actual purge S ^ O <br /> Depth to water L/ 4, <br /> Startur e 16 Sampling time °� 2 <br /> p g � -- <br /> Time Temperature E C PH Turbidity Volume <br /> CL <br /> 91 / 9 T <br /> Sample appearance 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 /> SRemarks <br /> Signature <br />