Laserfiche WebLink
® DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br /> WELL ACCESS SHEET <br /> Address: t9 qqD S P—C> Date: <br /> Resident/Owner Name: °q-ti-z) <br /> Sampling Date/Time: b l�o (Estimated sampling time is 15 to 20 minutes) <br /> Access Issues(Locks,Animals/Pets,Other); <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 /> Acknowledament- <br /> Ej <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 /> 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: L T66W. 'L <br /> lRemarks : <br /> Field Certification: Date: j f <br />