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2. Type(s) of Sample Requesting

   1. Bacteriological
   2. Inorganic Chemical (Mineral)
   3. Nitrate
   4. Petroleum
   5. Pesticide
6. Instructions

   1. Please complete all sections of this form and submit with payment to: Richmond County Health Department, 127 Caroline Street, Rockingham, NC 28379.
   2. No service will be conducted prior to payment being received in our office.
   3. Notify the Environmental Health Specialist prior to 9:30 am on scheduled appointments.
   4. Your well casing must be uncovered (for inspection) and properly sealed (no openings in well seal).
   5. The water spigot is accessible (sample bottle must “fit” under spigot in sanitary manner).
   6. The well pump is operating properly (electricity provided).
   7. Please allow 2 weeks to receive results for bacteriological well samples and 3 weeks on all other samples.
10. Tax Parcel Number of Property to Be Serviced
12. Property Owner Name
14. Address of Property to Be Serviced
    (Subdivision, Mobile Home Park, and Lot Number)
16. Directions to Property to Be Serviced
18. Address Where Results Are to Be Mailed
20. Daytime Phone Number
22. Daytime Fax Number
24. Are there dogs at the property?

    1. Yes
    2. No

    If dogs are present, they must be restrained at the time of inspection.
28. Bacteria Sample Information
    A bacteriological sample may only be taken from a properly protected well. The $30.00 fee will not be refunded if your well is not properly constructed and cannot be sampled. However, if the well construction is brought up to minimum standard within one year from the application date, no additional fee will be charged for a bacteriological sample.
32. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
34. Authorized Person Electronic Signature*
36. Date*
    Date
40. Well, House & Septic Tank Locations Upload
    If a record card cannot be found by the Richmond County Health Department please upload a drawing of the well, house and septic tank locations.
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field