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• <br />0 <br />DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />Address: 39-L Sc,tnrw Date: (0(uli'7 <br />Resident/Owner Name: TY�d� ic- i ►kn4'r n h .rc�► <br />Sampling Date/Time: to 1-W! 1-3 103C) (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): <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 />Acknowledement: <br />4� 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, and <br />® I must to be present during the sampling event, or <br />I d0 not need to be present during the sampling event. <br />I do not agree to participate in the Forward Landfill Domestic Well Sampling Program. <br />Signature: <br />Print: u, K(L)J C9 <br />Remarks: cGj r ' c� <br />_ (�� <br />G / (o �--- <br />Field Certification: Date: q, 2 1 <br />S^rnPled cry r tc11.1t %td•e OF bcz cls <br />F ©rC--lr,tF iC.5�ki�'rorc, <br />�1-ic, b�Gk�ard <br />alOU S� <br />