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DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br /> WELL ACCESS SHEET <br /> Address: //D ,- Date; d <br /> Resident/Owner Name: <br /> Sampling Date/Time: l (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 /> Acknowledginent: <br /> ED"lagree 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 /> ED1 do not agree to participate in the Forward Landfill Domestic Well Sampling Program.. <br /> Signature: <br /> Print: L-60 2 Er (C r tom' <br /> Remarks: 0 `' ' <br /> Field Certification: Date: <br />