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• <br />• <br />C7 <br />DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />Address:�'L)�6f <br />D n h q QQQ <br />Date: (1 <br />Resident/Owner Name: <br />Sampling Date/Time: W 114 % (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): tjt!LLrd <br />Additional Well Info. (construction, pump depth) : Hume- owners 'J'11 Lae �+w��.s► w�ar,.'T�"' <br />Well Use (last time used, purpose): If rjiet V V-% <br />Sampling is limited to analysis for volatile organic compounds. Results of the sampling program <br />will be used to assess the need for future semiannual sampling events at your well. <br />Acknowled me <br />I agree to participate in the Forward Landfill Domestic Well Sampling Program and <br />authorize sampling of my well at no cost to me. I understand that I will be provided with <br />a report with the sample results when they are available. Additional sampling may occur <br />ve— semiannually, and <br />I must to be present during the sampling event, or <br />I do not need to be present during the sampling event. <br />1 do not agree to participate in the Forward Landfill Domestic Well Sampling Program. <br />Signature: <br />Print: Q Y►� ''� GS <br />Remarks: <br />Field Certificatio Date: o(o <br />VS <br />r <br />Gw�n�v^_5 mov.Y-No� io \4--k--I VN .��crk- St�tcr <br />�czv►r�a� ►hto hcx,;.C-- --%v-%d w'A\ e v -j+ <br />-�a►\k- -to sis c fF' Zr%a sa"nP1► 1S qv;�''� . <br />�@ resi�c�nce> <br />