Wisconsin Department of Natural Resources
dnr.wi.gov
Notice: Do not use this form for property transfer well inspection samples. This form is authorized by ch. NR
812, Wis. Adm. Code. This form will be used to determine pump installer compliance with bacteriological, nitrate and
arsenic water sampling requirements.
Instructions: The pump installer is required to submit the samples to a certified drinking water laboratory that
provides the test results electronically to DNR within 30 days of completion of the analysis. It is mandatory to complete
all shaded areas of this form.
Pump Work – Water Test Request
Form 3300-265 (R 9/14)
Collection Date (MM-DD-YY) Time
am
pm
Collected By License # (mandatory)
Owner's Name Owner's Phone Number
Owner's Street Address Well Address (Street or Legal Description)
City State ZIP Code Town or City County
Latitude
DEG MIN
.
Longitude
DEG MIN
.
Lat./Long. Method
Mail
Results
To:
Name
Address
City State ZIP Code
Do not use this form for Public
Water Compliance Samples.
Approx. Well Completion Date Wis. Unique Well #
NNNAA
Sampling Information and Test Requests
Previous Unsafe Following Pump Work
Pump Work – New Well
Pump Work – Entry into Existing Well
Reason for Test:
Bathroom Tap
Kitchen Tap Milkhouse
Pressure Tank Tap
Other
Installer must collect a second sample if the
first sample is invalid (e.g., older than 48 hrs.).
Sample Location:
Well Construction Information
Drilled
Jetted
Driven Point
Dug
Other
Driller (if new well)
Bacti
Required:
Bacti
Required:
Nitrate Arsenic
Laboratory Use Only
Membrane Filtration
Fermentation Broth
Presence/Absence Enzyme Substrate
Other
Approved Method:
Laboratory Results
Safe (Coliform Absent)
Unsafe (Coliform Present) and:
Invalid (Submit another sample)
Bacteriological Interpretation:
Fecal/E Coli Present Fecal/E Coli Absent
Old - OL
Overgrown - OG
Turbidity - TU
Chlorine Present - CL
Frozen - FR
Lab Accident - LA
Shipping Problem - SP
mg/L as N
Nitrate:
Date / Time Received
Lab Sample No. Date Reported
Arsenic:
µg/L
Wisconsin Department of Natural Resources
dnr.wi.gov
Notice: Do not use this form for property transfer well inspection samples. This form is authorized by ch. NR
812, Wis. Adm. Code. This form will be used to determine pump installer compliance with bacteriological, nitrate and
arsenic water sampling requirements.
Instructions: The pump installer is required to submit the samples to a certified drinking water laboratory that
provides the test results electronically to DNR within 30 days of completion of the analysis. It is mandatory to complete
all shaded areas of this form.
Pump Work – Water Test Request
Form 3300-265 (R 9/14)
Collection Date (MM-DD-YY) Time
am
pm
Collected By License # (mandatory)
Owner's Name Owner's Phone Number
Owner's Street Address Well Address (Street or Legal Description)
City State ZIP Code Town or City County
Latitude
DEG MIN
.
Longitude
DEG MIN
.
Lat./Long. Method
Mail
Results
To:
Name
Address
City State ZIP Code
Do not use this form for Public
Water Compliance Samples.
Approx. Well Completion Date Wis. Unique Well #
NNNAA
Sampling Information and Test Requests
Previous Unsafe Following Pump Work
Pump Work – New Well
Pump Work – Entry into Existing Well
Reason for Test:
Bathroom Tap
Kitchen Tap Milkhouse
Pressure Tank Tap
Other
Installer must collect a second sample if the
first sample is invalid (e.g., older than 48 hrs.).
Sample Location:
Well Construction Information
Drilled
Jetted
Driven Point
Dug
Other
Driller (if new well)
Bacti
Required:
Bacti
Required:
Nitrate Arsenic
Laboratory Use Only
Membrane Filtration
Fermentation Broth
Presence/Absence Enzyme Substrate
Other
Approved Method:
Laboratory Results
Safe (Coliform Absent)
Unsafe (Coliform Present) and:
Invalid (Submit another sample)
Bacteriological Interpretation:
Fecal/E Coli Present Fecal/E Coli Absent
Old - OL
Overgrown - OG
Turbidity - TU
Chlorine Present - CL
Frozen - FR
Lab Accident - LA
Shipping Problem - SP
mg/L as N
Nitrate:
Date / Time Received
Lab Sample No. Date Reported
Arsenic:
µg/L
