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0 DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />• <br />0 <br />WELL ACCESS SHEET <br />Address: 2 `< ot ''S ✓ Date: Z <br />Resident/Owner Name: �.e— G. i <br />Sampling Date/Time: ��-7_ (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 />Acknowledgment: <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 I will be provided with <br />a report with the sample results when they are available. Additional sampling may occur <br />semiannually, and <br />M1 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 />Print: <br />Remarks: <br />Field Certification: Date: 6/)/// <br />