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® DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br /> WELL ACCESS SHEET <br /> Address: 11(65 I� Date: Z�C <br /> Resident/Ownet Name: R"w4 W►t�'-('��( <br /> Sampling Date/Time: h _ (Estimated sampling time is 15 to 20 minutes) <br /> Access Issues(Locks,Animals/Pets,Other): S C t e j <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 /> Acknowledement: <br /> 01 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 /> Q 1 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 /> { nff <br /> Print: <br /> Remarks : <br /> Field Certification: Date: <br />