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DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br /> WELL ACCESS SHEET <br /> rc�o <br /> Address: M& Date: <br /> f <br /> Resident/Owner Name: / l�(, P �MA.4 =g <br /> Sampling Date/Time: b� Z b (Estimated sampling time is 15 to 20 minutes) <br /> Access Issues(Locks,Animals/Pets,Other): C9Q iG Ty6 <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 /> Acknowledg!4ent: <br /> M'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 /> Fr7jI <br /> must to be present during the sampling event,or <br /> Q 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: j (A <br /> Remarks. c2()9- 9g& <br /> Field Certification: Date: <br /> • <br />