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DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br /> WELL ACCESS SHEET <br /> yr <br /> Address: 13 D I� 'E //1y�19 1' I e o S'4 Date: 6 • I q�-c9,0!`] <br /> Resident/Owner Name: PL-:#t1f <br /> C <br /> Sampling Date/Time: %3S2- (Estimated sampling time is 15 to 20 minutes) <br /> Access Issues (Locks,Animals/Pets, Other): 'f'i l l Doi S <br /> Additional Well Info. (construction, pump depth) : ,C (-�a f1 Ql Q. rlo!),necfed <br /> TIM <br /> Well Use(last time used, purpose): Wo1 <br /> wylo <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 /> I agree to participate in the Forward Landfill Domestic Well Sampling Program and <br /> authorize sampling of my well at no cost to me.l 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: (—Agew—, <br /> Print: 2 , wl <br /> Remarks <br /> Field Certification: Date: 6—e9,-Va/7 <br /> • <br />