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DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br /> WELL ACCESS SHEET <br /> Address: Date: <br /> Resident/Owner Name: 1G,{ <br /> Sampling Date/Time: (Estimated sampling time is 15 to 20 minutes) <br /> Access Issues(Locks,Animals/Pets,Other): d,3Q..q <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 /> Acknowied ents <br /> y 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 /> T / <br /> Print: ZiC.,i E,2 <br /> Remarks <br /> Field Certification: Date: I <br />