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DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />Address: Date: 1 <br />Resident/Owner Name: /Ills? i 5 E /- Q 1,5T <br />ampling Datetrime: ' (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): <br />dditional 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 />AcknowledgMent• <br />agree to participate In the Forward Landfill Domestic Well Sampling Program and <br />authorize sampling of my well at no cost to me. l 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 />® 1 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 />6 � <br />Signature: <br />Print: <br />Remarks: <br />Field Certification: Date: I' <br />