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• <br />• <br />DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />Address: 3 5W 54,n n y R -d Date: L:.It-% ':I <br />reside'nOwner Name: G VA /14? -0/ A/ <br />Sampling Date/Time: jp (Estimated sampling time is 15 to ZO minutes) <br />Act_- <br />Access Issues (Locks, Animals/Pets, Other): <br />�9P�c:,d} fu 1iaC1\ �'1Ggc� wOV\di �1 <br />Additional Well Info. (construction, pump depth) : F To <br />Well Use (last time used, purpose): <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 />Acknowledgment: <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 />semiannually, and <br />I must to be present during the sampling event, or <br />® Ido not need to be present during the sampling event. <br />I do not agree to participate in the Forward Landfill Domestic Well Sampling Program. <br />Signature: <br />Print: <br />Remarks <br />Field Certification: k Date: Lb I I"1 <br />��`-/g) 3is 6 <br />X0/30; 3 `x,32, <br />Su o n cj R Gl . <br />X110 �Ay �;� flr <br />SS g5 VS9 <br />I--rj <br />A\\ addrG55 <br />2 o%ssoC, ICA .� <br />3 3 0I ona we-\\ <br />5inI <br />bwvwy- IV\ Eo <br />