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• DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />Address: -14$,5 iN g4 Ic lZepokCi Date: U, ( Z 1 <br />Resident/Owner Name: Ghrt�t�tnA Zd.r,n�rc+ , <br />Sampling Date/Time: Agut Jt" 1 (Estimated sampling time is 15 to 20 minutes) <br />We- 11 ►rte V".aac=.� l bl =AA-- ymrd <br />Access Issues (Locks, Animals/Pets, Other): t c=� a,F <br />awv��r r�nc►-���cr��d thy-} <br />Additional Well Info. (construction, pump depth) : +A,% do <br />Well Use (last time used, purpose): Err <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 />Acknowledament: <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 />I must to be present during the sampling event, or <br />O I do not need to be present during the sampling event. <br />I do not a ee to participate in the Forward Landfill Domestic Well Sampling Program. <br />Signature:J�n�" " �~ <br />Print: <br />Remarks: It-�oc.lt �..� c1�..— _('��-e •rv. salIr%r.� ►fr hp. C' %-I _ VS <br />Field Certification: Date: OJZA 1 1 <br />S <br />o't e - <br />e evr< P <br />W--% <br />ca Gx a o11 a c -t <br />4!r4:!57l a s c.-% F 14e . <br />J <br />