Free 36741.PDF - Indiana

PRIVATE WATER SUPPLY REPORT
Shipping No. _________________

INDIANA STATE DEPARTMENT OF HEALTH
Environmental Microbiology 635 North Barnhill Drive, Room 13G P.O. Box 7202 Indianapolis, Indiana 46207-7202

Sample Number ______________

Date Rep. ___________________

Date Received _______________ ANALYSIS DATA

SAMPLES SUBMITTED WITHOUT COMPLETED FORM WILL NOT BE ANALYZED. USE BLACK INK. Indiana State Department of Health is to mail report to: ________________________________________________
(Name)

TEST: TOTAL COLIFORM METHOD*: MF RESULT: MPN LST P/A MM P/A MM QT

________________________________________________
(Street)

PRESENT
(Zip)

__________________________ IN __________________
(City or Town)

ABSENT
ANALYST:

SAMPLE DESCRIPTION
Sample Source: ¨ Drilled Well ¨ Spring ¨ Dug Well ¨ Cistern ¨ Driven Well

TEST: METHOD*: MF RESULT:

FECAL COLIFORM

E. COLI

MPN

EC P/A

MM P/A

MM QT

County ________________________________________________ Owner ________________________________________________ Date Collected __________________________________________ Collected by __________________________ Depth ____________ Phone ________________________________________________ Water use by ___________________________________________ Location of water supply ___________________________________ Reason for examination ____________________________________ Age of well ____________ Location with respect to: Date of last repair __________________ privy _________ft. cesspool ________ft.

PRESENT ABSENT
ANALYST: *If MF is checked the result is organisms per 100 ml. If P/A is checked the result is presence (P) or absence (A) If MPN or MM QT is checked the result is the most probable number per 100 ml.

REPORT OF SAMPLES
SATISFACTORY: At examination time, this water was bacteriologically safe based on USEPA standards. At examination time, this water was bacteriologically unsafe.

Septic tank ______________ft. Sewers or drains ______________ft. Pump spout--open or closed ________ Require priming? _________ Well diameter ___________ Is cover watertight? ________________ For dug wells: Are walls watertight to depth of 10 ft.? _____________ Is wastewater carried away? _________________________________

UNSATISFACTORY:

PLEASE SUBMIT ANOTHER SAMPLE. TEST NOT VALID BECAUSE: ¨ Too long in transit (more than 48 hours).

For drilled or driven wells: Single or double tubular _______________ Is annular space between the two pipes sealed? _________________ Well pit? ________ Drained to ________ Depth cased ________ft.

¨ Invalid/no collection date. ¨ Sample type not designated. ¨ Other ______________________________________ Please see recommendations (on accompanying sheet) numbered: _______________________________________ Remarks:

For springs: Is it walled up and covered? ______________________ Can it be flooded? ________________________________________ For cisterns: Material of pipeline to cistern ______________________
SDH 44-007 State Form 36741 (R4 / 5-99)

DIRECTIONS FOR DESCRIBING, COLLECTING AND MAILING THE SAMPLE

I. 1.

DESCRIBING THE SAMPLE The regulations of the Indiana State Department of Health provide that samples of water shall not be examined unless they are collected in containers furnished for that purpose and the description blanks are filled out completely. COLLECTING THE SAMPLE A dechlorinating agent has been added to the bottle. It may appear as a white crystal, a drop of water, or a spot of powder two or three millimeters in diameter. It is sodium thiosulfate. Do not wash or rinse it out. The purpose of the bottles containing thiosulfate is to destroy the chlorine present at the moment the sample is collected. Sodium thiosulfate prevents the killing action of the chlorine on the bacteria while the sample is being transported to the laboratory. Water samples which contain chlorine residuals when they reach the laboratory will not be examined. A sample shall be taken from a tap, such as a faucet, petcock, or small valve. No sample shall be taken from a fire or yard hydrant or a drinking fountain. Kitchen sinks, threaded hose bibs, softened or treated water lines, and spigots with screens or aerators are poor sampling points and should be used only if better sampling points are not available. When the sample is to be collected from a tap, allow the water to run freely for at least five minutes to flush out pipes and fixtures. Time by a watch; do not guess. Remove the screw cap being careful not to touch or otherwise contaminate the inside part of the cap or the neck of the bottle itself. Reduce flow of water in tap to a steady stream about the size of a pencil. Fill the bottle exactly to the 100 ml line on the bottle. At this level, there will be 100 ml of water and about 25 ml of air space. Replace the screw cap using the same care as before.

II. 1.

2.

3.

4. 5.

6.

III. MAILING THE SAMPLE 1. Postal authorities require that the sample be packed and mailed in the following manner: a. Refold the description form in half lengthwise and wrap it around the bottle. Place the bottle inside the container. b. If the return address label (to the State Department of Health) is not already pasted to the package, moisten the back side of the enclosed gummed address label and paste it on the package. Make sure the return address appears on it. 2. Mail the sample immediately after collection. Time of collection of the sample should be governed by the time of mail pickup at the mailing station and the delivery at Indianapolis. The time between the sample collection and the arrival of the sample to the laboratory should not be more than 48 hours, preferably within 30 hours. If the postal service does not give satisfactory service in your area; in the future, you may wish to investigate other means of transporting the samples, such as UPS, Overnight Expresses or by bus.

SDH 44-007 State Form 36741 (R4 / 5-99)