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• DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />• <br />0 <br />Address: -*nq �- N uj Ge Spl— Date: lOf Zz11-7 <br />Resident/Owner Name: Kik 'aellcr< <br />Sampling Date/Time:1030 (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): SVD VY 6w— <br />WellAdditional Well Info. (construction, pump depth) : �lu*�P� 6n k it".2 C"+ o� '� w - <br />Well Use (last time used, purpose): "+- cin -oin. <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 />E�Imust to be present during the sampling event, or <br />I do not need to be present during the sampling event. <br />F-11 do not agree to participate in the Forward Landfill Domestic Well Sampling Program. <br />Signature: %'4 <br />Print:�1 �� <br />Remarks <br />-T+ <br />Field Certification: Date: <br />