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• <br />0 <br />DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />:.x,r♦ c� R hal <br />Address: W o. Date: <br />Resident/Owner Name: /�/�� <br />Sampling Datetrime: (2t/_02//AM �% (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): 6a -}c f <br />Additional Well Info. (construction, pump depth) : <br />Well Use (last time used, purpose): <br />Sampling is limited to analysis#or volatile organic compounds. Results of the sampling program <br />willbe used to assess the need for future semiannual sampling events at your well. <br />Adcnowledament• <br />1 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, an <br />I must to be present during the sampling event, pr <br />I do not need to be present during the sampling event. <br />1 do not agree to participate In the Forward Landfill Domestic Well Sampling Program. <br />Signature: <br />Print: <br />Remarks: <br />Field Certification: Date: <br />