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® DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br /> WELL ACCESS SHEET <br /> Address: Date: 4Q0j 1 1 <br /> Resident/Owner Name: <br /> Sampling Date/Time: /0)10 � (Estimated sampling time is 15 to 20 minutes) <br /> Access Issues(Locks,Animals/Pets,Other): oe 4ie We <br /> Additional Well info. (construction, pump depth) 4 d 50Llnf1e x+- `U <br /> A 1e e' ,, Yee WRS V%c.-we Prp"J)e` <br /> Well Use(last time used, purpose): -kar <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 /> Acknowledsment• <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,an <br /> I 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 agree to participate in the Forward Landfill Domestic Well Sampling Program, <br /> Signature: <br /> Print: i y loM 5 t" i <br /> Remarks: �'n 0 'Ao <br /> Field Certification: Date: 6 <br />