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• <br />0 <br />DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />Address: 2'-ksan • A 2cnc--.e4 Date: t_i -7-C!tTJ::3 <br />Resident/Owner Name: <br />Sampling Date/Time:�o ice" 1 i? -%S (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): 1�iolrle <br />Additional Well Info. (construction, pump depth) : <br />Well Use (last time used, purpose): <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 />Acknowleditment: <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 />I must to be present during the sampling event, or <br />I do not need to be present during the sampling event. <br />a1 do not agree to participate in the Forward Landfill Domestic Well Sampling Program. <br />Signature: <br />Print: <br />Remarks <br />Field Certification: Date: t►� Z+U I <br />