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• <br />• <br />DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />310. A'Cx' ���1.5" Date: <br />dent/Owner Name: <br />ling Date/time: U/1-18-7 <br />Issues (Locks, Animals/Pets, Other) <br />I Well Info. (construction, pump depth) : <br />I Use (last time <br />0/2.3//-7 <br />(Estimated sampling time is 15 to 20 minutes) <br />';Y'f I*d;6b-- lYl <br />rk-' .�r Z'-� % s <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 />Signature: <br />Print: <br />Remarks <br />Field Certifi <br />Acknowleditment: <br />t 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, ph <br />211 must to be present during the sampling event, gr <br />= I do 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 />r <br />J_ld 1c/ i d P/gZe- <br />Date: W13 fl -7 <br />