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• DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />• <br />C, <br />Address: S4-4-1 sA,r,r%ji 2QL4ZX= Date: lQ_ IT2oT 1:3 <br />Resident/Owner Name: _ Sue-- <br />Sampling <br />vcSampling Date/Time: u 12C> 11-1 1,11 C> (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): <br />Additional Well Info. (construction, pump depth) : an r.ot%!,k E=CAM+ G <br />w�,\\ 1c�G•q.�-Gcl► th l�G.k-EcJ► Shed. <br />Well Use (last time used, purpose): �1.►,•-� <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 />Q 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: <br />Print: 5%A'e oh <br />Remarks: <br />Field Certification: S., Date: U12011-7 <br />Qlcasc kYncc.1L 01h olckar Ejgry cr <br />Su c) i4r--"C>.Z 1ov ouo.Vn'j Ac:' <br />resamPle �vcll, <br />pL,,:,hcr rr\r- I CW -1 CAIC-tvw-., dePOSi+S n <br />LoF�CG �?cx� �r(r1ds. <br />