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DOLLOS ENVIRONMENTAL, INC. SAMPLING INFORMATION SHEET <br /> Client Ultramar Sampling Date <br /> �` Site Beacon #3641 Protect No r <br /> 1210 E Hammer Lane 1400 Well Designation /VL W Q <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 level'? NO If no, see remarks <br /> Is well cap sealed and locked9 NO If no, see remarks <br /> Height of Nell casing riser(in inches) 3 <br /> WeII coN er type 8" or 12"UV 12" EMCO 8"or 12"BK 8"Christy <br /> 12"Christv 8"M&D 12"M&D 12"DWP <br /> 12"CNI 36"CNI 12"Pomeco Other 2 f'/'✓1 <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 ,X Centrifugal pump <br /> Sampled with Disposable bailer < Teflon bailer Disposable Tubing <br /> WeII Diameter 2" X 4" 6" 8" <br /> Purge N of Multiplier 0 16 065 1 47 261 gal/ft <br /> Initial Measurement Recharge Measurement <br /> Time ' r" 1 Time '7 " 0 fCalculated purge <br /> Depth of well S Depth to water I Actual purge Y f <br /> Depth to water <br /> S[artpurge (j S Sampling time <br /> Time Temperature E C pH Turbidit Volume <br /> -2 �00 f7 14 <br /> Sample appearanceLock <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 (DAT) <br /> .Remarks <br /> Signature <br />