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C7 <br />E <br />Ll <br />DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />�Address: _Pq 0 5-1 �"ax e7-1 Date;12,017 <br />:Resident/Owner Name: <br />Sampling Dateme: JA 7 f (Estimated sampling time is 15 to 20 minutes) 7 <br />!Access Issues (Locks, Animals/Pets, Other): Ln� <br />y• Well Info. (construction, pump depth): 40_Ve'r t --h4. <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 />Admowleclament: <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 />EErmust to be present during the sampling event, or <br />I do not need to be present during the sampling event. <br />=Idono agree to participate in the Forward Landfill Dois <br />mestic Well Sampling Program. <br />I�Slgnature: <br />!Pri6f. 4 - <br />Remarks: jo*�- C 2 <br />Lit■.+n: <br />a <br />