Form Center

Please fill out the form below.
By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.


  1. ochd
  2. Call before sampling.
  3. Instructions
    NOTE: UPDATES ON THE SAMPLING AND THE REPORTING OF RESULTS WILL BE SENT TO THE EMAIL ADDRESS. YOU WILL ACCESS YOUR RESULTS BY SEARCHING PUBLIC RECORDS WITH YOUR ADDRESS, PIN, OR WS# Payment must be received in order to complete the services. Since online payments cannot be accepted at this time, please indicate your preferred method of payment on the form below.
  4. Rental?
  5. Owner Occupied?
  6. Any existing water treatment?
  7. Is this a NEW well construction?
    Payment is required. If payment is not received within 5 business days, this application will be held in pending and discarded after 30 days.
    Please select which type of sample(s) you are requesting.
    Water samples may be requested by the owner or tenant of the property. The well head and sampling spigots should be exposed and made accessible. Please do not chlorinate the well before sampling unless instructed to do so otherwise.
  11. *NOTICE: This office is not responsible for reporting delays by the lab. The majority of water sampling is analyzed at the NC State Public Health Laboratory. Chemical analysis can take several weeks. *
  12. By typing in my name, I authorize the Orange County Health Department to enter the property and to perform the service requested.
  13. Leave This Blank:

  14. This field is not part of the form submission.