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PRIVATE WELL TESTING ACT PROGRAM - page 55 / 75

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New Jersey Private Well Water Test Reporting Form

The New Jersey Private Well Test Reporting Form is a standardized form to be used exclusively by laboratories reporting well test results to their client in accordance with the Private Well Testing Act Regulations N.J.A.C. 7:9E.

These laboratory analyses were completed for the purposes of complying with the Private Well Testing Act. In accordance with the Private Well Testing Act Regulations all analytical results except for coliform (total, fecal, or E. coli) shall remain valid for a period of one year from the date of sample collection. All coliform (total, fecal, or E. coli) analytical results shall remain valid for a period of six months from the date of sample collection.

  • Analytical results meet primary and secondary contaminant standards for drinking water

  • One or more of the analytical results do not meet primary + contaminant standards for drinking water

One or more of the analytical results do not meet secondary standards for drinking water

++

contaminant

CLIENT INFORMATION: Name:

__________________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date Test Requested:

Mailing Address & Phone #:____________________________________________________________________________________

PROPERTY INFORMATION: Property Address: _______________________________________

Municipality: _____________________

Muni Code (4 digit):

_ _ _ _ _ _

C o u n t y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Property Lot:

____________________________

Block:

GPS Location- State Plane Coordinates (feet): (X) _____________________

(Y) _____________________

GPS Coordinate Origin (Circle One): Well Head/ Front Door/Sample Collection Point/Other (Explain): _______________________________

NJ Well Permit or Well Record Number: _________________________________________________________________ (if known)

LABORATORY INFORMATION: Reporting Laboratory Name & ID #:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Reporting Laboratory Address & Phone #: _________________________________________________________________________

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