413 Georgia RdWATER SAMPLE/SEWAGE SYSTEM CHECK REQUEST
• DAVIE COUNTY ENVIRONMENT L HEALTH SECTION
Date Requested:
Received By
WATER SAMPLE TYPE:
Bacterial
O Protected
O
C1j
Chemical
Other:
O Unprotected O Dug
O Bored O Drilled
Outside Spigot: rl-ON� tr.D14C4
.-f eXf
O Other:
SEWAGE SYSTEM CHECK: O
Yes Vacant:
O Yes O Approved
/� O No O Disapproved
Owner's Name:
Buyer's
Nae
Property Address: 3
Directions:
Special Instructions:
Letter To:
Closing Date:
Attn:
-----------.--------
Date Taken: to
Charges:
Telephone:
By:
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DECEIVE®
OCT 112011
North Carolina State Laboratory Public Health P.O. Box 28047
,7 306 N. Wilmington St.
Environmental Sciences Raleigh, NC 27611-8047
htti):/Islr)h.ncpublichealth.com
Microbiology Phone: 919-733-7834
Fax: 919-733-8695
Certificate of Analysis
Report To: Name of System:
DAVIE CO ENVIRONMENTAL HEALTH PAM GILPIN
P O BOX 848 413 GEORGIA RD
MOCKSVILLE, NC 27028 MOCKSVILLE, NC 27028
EIN:566000295EH COURIER M 09-40-06
StarLiMS Sample ID: ES100611-0035001
11111111111111 I I 1111111111111111111111111111111111111111111111111111111111111111111111 IN
ES Microbiology ID: 30993
GPS Number:
Sample Description:
Comment:
Collected: 10/05/2011 11:00
Received: 10/06/2011 08:21
Sample Source: Well
Sampling Point: Outside spigot
Andrew Daywalt
Darneice Lyons
Well Permit Number:
Environmental Microbiology - Colilert Profile Method: SM 9223B
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Present - Darneice Lyons 10/07/2011
E. coli, Colilert Absent Darneice Lyons 10/07/2011
Report Date: 10/07/2011 Reported By: Susan Beasley
'F1. 6
Explanations of Coliform Analysis:
If coliform bacteria are Absent, the water is considered safe for drinking purpose. If coliform bacteria are Present,
the water is considered unsafe for drinking purpose. Presence of E. coli (bacteria) generally indicates that the water
has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sample
received and should not be regarded as a complete report on the water supply.