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0 <br />0 <br />DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />Address: E ?J�J Ia(7 5uAY�.A �j d Date: tilu J/ 7 <br />dI <br />109RDiowner Name: OY-'T' <br />Sampling Date/Time: �/U/ /-7 (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): 04-- d0°1'. JAf 6*Jl dy ft'(WdC P'v ef �C <br />Additional Well Info. (construction, pump depth) : SC -4e L Li u -,.j , k 3,%Q; -A i, <br />(&mi5s, b- + Icti <br />Well Use (last time used, purpose): AW 14 1 r,r I o ~- <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 />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 l 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 />1 do not agree to participate in the Forward Landfill Domestic Well Sampling Program. <br />Signature: -\eV-'F ,/11drd <br />Print: _ yz5 F. - _ _ prd <br />Remarks: <br />Field Certification: Date: 6� 2V/7 <br />,o / iku`< <br />