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• <br />0 <br />DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />?.1"34 S"Vn hn j 20 1--AcTA Date: t& I -2 - Mm i ►—t <br />Name: M a.n" P c--Xnr1y <br />mpling Date/Time: _ , �7c� 1► -1 i t 5Q <br />Issues (Locks, Animals/Pets, Other): <br />al Well Info. (construction, pump depth) : <br />Use (last time used, pu <br />(Estimated sampling time is 15 to 20 minutes) <br />W�ti loc �.�cc�► car +M1c t-'% <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 />Acknowledgment: <br />191I 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 />rNM I do not need to be present during the sampling event. <br />= I do no agree to participate in the Forward Landfill Domestic Well Sampling Program. <br />rks : <br />Certification: <br />Date: <br />i c�G <br />►�ao�c 3"13{- �.nca 3-1 <br />S <br />