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$A C, Case # SAM-10-09-1903
CATAWBA COUNTY HEALTH DEPARTMENT
V~ Environmental Health Section
1$ 42 SM 10/22/2009
WATER SAMPLE FIELD REPORT
- - - -
APPLICANT OWNER
PAMELA SIGMON PAMELA SIGMON
3486 OXFORD SCHOOL RD 3486 OXFORD SCHOOL RD
Catawba NC 28609 Catawba NC 28609
(828)446-5178 (828)446-5178
Site Address 3486 OXFORD SCHOOL RD, Catawba, NC
Name of Subdivision
Parcel Number 378201189081 Lot 1 Block
Specific Directions OXFORD SCHOOL RD TOWARDS CATAWBA - MODOLAR HOME ON LEFT 1/2 MILE FROM I-40
Initial Collected by: A P Date/Time Sampled: /0 2,2 - / v 5 S,+A
Type of Sampling Point: !fit 14-z 11
Well New or Existing? New Existing
Type of Well: Drilled Bored v Dug Spring City
Resample collected by: Date/Time Sampled:
Date of Well Installation:
Reason for Sample:
Does well meet adequate construction standards from what can be observed: Yes ✓f No
Reason for non-compliance: Defective well cap and / or seal
Piping does not exit through top of well by approved cap and sanitary well seal
Evidence of improper grouting or no grouting
Opening in the well casing or cap
Supply too close to source of potential contamination
Notification: Existing well owner notified that well does not meet adequate construction ? Yes No
Date of Notice:
Improvement: Existing well improved Yes No Date of Inspection:
RECEIVED
OCT 2 6 2009
CATAWBA COUNTY
ENVIRONMENTAL HEALTH
10/22/2009
4,A C Case # SAM-10-09-1903
CATAWBA COUNTY HEALTH DEPARTMENT
v Environmental Health Section
$ ! Z sM 10/22/2009
WATER SAMPLE TEST RESULTS
APPLICANT OWNER
PAMELA SIGMON PAMELA SIGMON
3486 OXFORD SCHOOL RD 3486 OXFORD SCHOOL RD
Catawba NC 28609 Catawba NC 28609
(828)446-5178 (828)446-5178
Site Address 3486 OXFORD SCHOOL RD, Catawba, NC
Name of Subdivision
Parcel Number 378201189081 Lot I Block
Specific Directions OXFORD SCHOOL RD TOWARDS CATAWBA - MODOLAR HOME ON LEFT 1/2 MILE FROM I-40
Lab Coliform Anallsis Results: Total Coliforms: (I DWI&
Fecal / E. Coli: a
Invalid Results: No Collection Date Over 30 hours old
Excessive turbidity Excessive Chlorine
Lab Accident
Lab Tech Initials Date/ Time Received Date/ Time Completed
10/22/2009