COUNTY OF RANDOLPH
Health Department
204 E Academy St - Asheboro, NC 27203
LOCAL TELEPHONE NUMBERS
Asheboro: (336) 318-6262 ● Archdale/Trinity: (336) 819-3262
http://www.randolphcountync.gov
Water Sample Application (EHWS 1) Rev. 9/5/2019
WATER SAMPLE APPLICATION
Applicant: ________________________________ Date: ____________________________________
Address: __________________________________ Application #: ______________________________
City, ST ZIP _______________________________ Parcel number: ____________________________
Owner: __________________________________ Contact name: ____________________________
Address: _________________________________ Contact phone: ____________________________
City, ST ZIP ______________________________ Contact e-mail: ____________________________
LOCATION INFORMATION:
Location: ________________________________________________________________________________
Subdivision: ______________________________ Lot number: ______________________________
WELL AND WATER INFORMATION:
Facility Type: ______________________________ If No, Specify Location: ______________________
Well Type: ________________________________ Water Treatment System Present: _____________
Well Location: _____________________________ Treatment Type: ___________________________
Faucet at well: _____________________________
WATER SAMPLE INFORMATION:
Type of water sample needed: _______________________________________________________________
Additional water sample needed: _____________________________________________________________
Additional water sample needed: _____________________________________________________________
COMMENTS: ____________________________________________________________________________
________________________________________________________________________________________
AUTHORIZATION TO PROCEED:
I have read this application and certify that the information provided herein is true, complete and correct.
Authorized County and State officials are granted right of entry to conduct necessary inspections to determine
compliance with applicable laws and rules. I understand that I am solely responsible for making the site
accessible so that a water sample can be collected.
____________________________________________ _______________________________________
Signature of property owner/legal representative Date
Select the well location.
Type of water sample needed.
Type of water sample needed.
Type of water sample needed.
click to sign
signature
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