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• DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />• <br />is <br />Address: 3q l 5 V" !! 0-a • Date: 641 1 IZ-01 -7 <br />Resident/Owner Name: h1c6c,14411n2 yy.'61 <br />` <br />Sampling Date/Time: %-G I ZI ( k -i (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): %:mac c:,F <br />1nc�� �tCr-ic.� c.lr:VGva[xy <br />Additional Well Info. (construction, pump depth) : <br />Well Use (last time used, purpose): IV -r <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 />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 rqpst to be present during the sampling event, or <br />YT"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: <br />/1, r,, /-- <br />Print: b <br />Remarks <br />09 <br />Field Certification: Date: (rr ZI i -7 <br />`cav1 G�t'S"i a SG• m pie <br />