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• <br />• <br />DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />Address: 3320 T j2 r--e>e!j Date: U12-% t"1 <br />Resident/Owner Name: A y-%Acmn%c!% Arer-�d►o <br />Sampling Date/Time: La -1 ri (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): --.Ltq" Inu=t <br />Additional Well Info. (construction, pump depth) : <br />Well Use (last time used, purpose): %V -Y -% CX ► l i� <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 />Acknowled>ament: <br />DT, 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 />I do not agree to participate in the Forward Landfill Domestic Well Sampling Program, <br />Signature: 7, 01' <br />Print: <br />Remarks: <br />Field Certification: ZZ Date: t2 <br />cc�l1 Irl S�EAn►1S <br />�G- will vStc� F'or �r►��r� ►�►-�csbi tc 'nav-in�xri�.� h� <br />�cc.�,�5g -tom well I+S�t f' � 1nS+r_t-td� .�ckmPle tact Ic.eh Fro+ <br />kcl�,; e. L f h + � o► � of ►--e_�; . <br />