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E <br />DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />dent/Owner Name: <br />)pling Date/Time; (Estimated sampling time Is 25 to 2D minutes) <br />i -;Ss Issues (Locks� Animals/Pets, Other): <br />Well Info. (construction, pump depth): <br />Well Use (last time used. purpose): <br />Sampling Is O to anahos 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 />I agree to participate In the Forw*ard 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, 9M <br />I must to be present during the sampling event, or <br />Idonot need to be present during the sampling event. <br />1 &_ng_t agree to participate in the Forward Landfill Domestic Well Sampling Program. <br />1 11, <br />TN <br />12 <br />MR11=1 <br />