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Appendix 6: Well Water Study Application <br />Mill Creels Road Area <br />Well Water Study <br />Application <br />APD # WSOS- <br />OWNER: <br />ADDRESS <br />PHONENUMBBR <br />SUBDIV[SION / L <br />Orange County Health Department ~-~j <br />Environmental Health Division <br />P.O.Box 8181,306-C Revere Road <br />Hillsborough, NC 27278 <br />www.co orange.nc.us <br />TMBL. # <br />_ PI-ZONE NUMBER <br />DIRECTIONS /LOCATION _ <br />DATE DR11~L6D <br />HAS THIS WELL BEEN SAMPLED BY OCFID 13L=PORB? N^ <br />WHEN WAS THE WELL LAST CI-ILORINAT6D? <br />DESCRtBL- ANY CUR.REN7 PROBLEMS WITH YOUR WATER <br />APPLICANT: <br />ADDRESS <br />Y^ GIVE DATL- AND RESULTS <br />IS 7HL•RE A TREATMEN~i SYSTEM'? N^ Y^ <br />WI1AT TYPL•? O Filler O Softener O Neutralizer <br />O Chlorinator O Ultraviolet Light O Other <br />WATER SAMPLES MUST BE REQUESTED HY THE OWNER OR TENANT WITH A SIGNATURE AUTIIORIZING THE OCHD TO ENTER THE <br />PROPER'iY l"O COLLECT TFIG SAMPLES <br />TI18 WELT. iIEAD AND SAMPLING SPIGOTS MUST BE EXPOSED AND MADE ACCESSIBLE TO THE OCHD <br />THE WELL SHOULD NOT BE CFILORINATED PRIOR TO SAMPLING UNLESS INSTRUCTED BY THH OCIiD <br />IfE2Ff3}':1 UTHORI7_G THE OCHD TO ENTL• R THC• PROPC•RT)' AND P£RFORA~f THE SERI'/C[ RLOUC•STLD <br />OWNER/TENANT: DATE: <br />RETURN THIS rORD1 TO: ORANGE COUNTY I-IL-AL~T[-1 D6PARTML-NT, <br />ENVIRONMENTAL. HEAL~TI-1 SERVICES DIVISION: <br />.306-C RL• V ERL- RD , <br />1-IILL.SBOROUGH,NC 27278 <br />OR TO T11E FIOLL.OWAYS (GLGNDA OR. 106) AT-4620 MILL CREEK ROAD <br />~• ® C ~ ~ ~ • <br />Sample Collection Information: <br />Bacteriological: by , RS <br />Inorg Chemical: by , RS <br />Petroleum: by , RS <br />Pesticide: by ' RS <br />by , RS <br />Radon (water): <br />Radon (air): by , RS <br />Page 44 of 47 <br />