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• <br />is <br />0 <br />DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />Address: J—� JITG Y1 16, W tq Dater <br />Resident/Owner Name: � I Y-1 C4 VY <br />Sampling Date/Time: (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): �IlX�l,�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 />ftknowledameM• <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 1 will be provided with <br />a report with the sample results when they are available. Additional sampling may occur <br />semiannually, and <br />IT'S 1 must to be present during the sampling event, or <br />O I do not need to be present during the sampling event. <br />1 do not agree to participate in the Forward Landfill Domestic Well Sampling Program. <br />Signature: i / ► y ► i <br />Print: YX4,4! if Vl: _ 4;;277,' <br />Remarks: <br />Field Certification: Date: <br />