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• DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />• <br />Address: _70$I> 1yWCA!&rip_ 9`00L1 Date: -7 <br />Resident/Owner Name: �cl l of <br />Sampling Date/Time: Y/7,1-11-7 (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): NOK -e- WkKW-'S&M212 igan -0vI-- <br />1 �5►sc. �, .�,ttiyc., su ►w ��, (,�y, <br />Additional Well Info. (construction, pump depth) 5ir4V, <br />Well Use (last time used, purpose): �IG <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 />Q1 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 />1 must to be present during the sampling event, or <br />C�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: C. se- <br />Remarks: <br />e-Remarks: <br />Field Certification: Date: (a✓ <br />ri <br />V1 <br />