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DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br /> WELL ACCESS SHEET <br /> Address: S<--. Date: 6Z2-( l I <br /> Resident/Owner Name: a±tL <br /> Sampling Date/Time: a/// 7 (Estimated sampling time is 15 to 20 minutes) <br /> Access Issues(Locks,Animals/Pets,Other): 1VD <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 /> Acknowledrtment: <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 /> ® 1 must to be present during the sampling event,or <br /> I do not need to be present during the sampling event. <br /> aI do not agree to participate in the Forward Landfill Domestic Well Sampling Program. <br /> Signature: A Print: 4�1- <br /> 44 ck �� T4 <br /> Remarks <br /> 5 - q2t - 3 <br /> Field Certiflcation: Date: <br /> • <br />