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0, <br />DOMESTIc/muma'PAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />ddress: ON Date: p <br />Resident/Owner Name: <br />mpling Date/1"ime: oI (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): <br />Additional Well Info. (construction, pump depth): <br />ell Use (last time used, pur eej <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 />MMee to participate In the Forward Landfill Domestic Well Sampling Program and <br />orize 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, ad <br />must to be present during the sampling event, Qr <br />I d2 get need to be present during the sampling event. <br />El I do pRt agree to participate in the Forward Landfill Domestic Well Sampling Program. <br />Signature: <br />Print: <br />Remarks: <br />Field Certification: Date: <br />