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• <br />• <br />DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />Address: Date: i-0 2�� <br />Resident/Owner Name: L <br />Sampling Date/Time: LQ f 21 1'l 11! -C (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): 0��� <br />Additional Well Info. (construction, pump depth) <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 />Acknowieditment: <br />1X1 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 />1 must to be present during the sampling event, or <br />I do not need to be present during the sampling event. <br />I do not agreq4 participate in the Forward Landfill Domestic Well Sampling Program. <br />Signature: <br />t <br />Print: <br />Remarks <br />Field Certification: Date: to Z1 ? <br />i_l n'e-Aq vY'1c.uyr Firs a-alc- 1 e= W' Vs sc-,v-,, pI% r-ic{ -^A %—c r . <br />J � <br />�v j ..�►- rr r,-,•) Po k + 1'j C- C,,V-% CA Fr- Z e:.rNe4 i`i <br />