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Requisition for Bacteriological Testing of Well Water
INSTRUCTIONS FOR COLLECTION AND DELIVERY OF WATER SPECIMENS:
1. Before collecting water specimen, review the “Fact Sheet” (reverse).
2. Use only the sterile specimen container provided in this kit.
3. Take care to avoid touching the inside of the screw cap or container.
4. Allow water to flow freely from pump or tap for five minutes before taking specimen.
5. Fill container to the 100-mL mark and close lid snugly, ensuring lid is not cross-threaded. Do not overfill.
6. Label the specimen container as follows:
(a) Record the Landowner’s name on the container label (use the line designated “ID.
” on both the lid
and the bottle. Note: The landowner’s name on the specimen container must exactly match the landowner’s
name on the requisition (below). Unlabeled or mislabeled specimens will NOT be processed.
(b) Record the date and time of specimen collection on the container label (use the line designated “Date
on the lid of the container).
”
7. Complete the information requested on the bottom of this form.
8. Immediately following collection, deliver the specimen and this completed form to a patient care centre location (refer
to attached location list). If a delay of more than 6 hours is unavoidable, the specimen should be refrigerated (not
frozen) until delivery. **Do not add ice to the specimen**
9. The fee for this testing is $60.00 (includes GST) payable upon delivery to a patient care centre or to DynaLIFEDx main
laboratory. Make cheque payable to DynaLIFEDx.
 Specimens received at the main laboratory more than 48 hours after collection are NOT suitable for testing.
 Failure to carefully follow the above instructions may cause the laboratory results to be misleading.
 Testing consists of bacteriological examination only (coliforms and E. coli only) – NOT chemical analysis.
Patient Care Centre:
Water Supply for (Landowner’s Name):
Specimen collected by:
Date Received:
Address:
Phone # of Collector:
(
)
Collection Date:
City, Town, Village:
Receipt #:
Postal Code:
Telephone:
(
Water Source:
Testing for:
Collection Time:
)
 Well
 Real Estate/Mortgage Purposes
Legal Land Description (MUST PROVIDE):
Location: ________________¼ Section______________Township___________Range______________w of _______th Meridian.
Is this a repeat test?
Is water chlorinated?
Results to be:
 Yes
 Yes
 No
 No
 Mailed to:
(provide identity of recipient and complete mailing address, including postal code)
 Faxed to:
(
)
(provide fax number with area code and name/identity of recipient)
 Picked up from DynaLIFE
 Picked up from DynaLIFE
DynaLIFEDx
Proprietary
Dx
main laboratory (Suite 200, 10150 – 102 Street, Edmonton AB)
Dx
patient care centre (please specify which location)
Doc ID: MIC-FM-0005608
Revised: 06-Aug-2013
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FACT SHEET – Bacteriological Testing of Well Water
Please read the following information before collecting a water specimen.
DynaLIFEDx provides bacteriological testing of water from wells as a service to the Real Estate Industry. In
the past, the service was available from the Provincial Laboratories of Public Health or through the local Health
Units. This service is no longer available.
1. Specimens that are unlabeled or mislabeled will not be processed.
2. Water specimens, other than well water, will NOT be processed.
3. Testing for total coliforms and fecal coliforms fulfill the requirements for Real Estate transactions and in
obtaining a CMHC or other mortgage.
4. A container with complete instructions may be picked up at many of our DynaLIFEDx patient care centres
(refer to http://www.dynalifedx.com for locations). After collection, the specimen may be dropped off at any
Patient Care Centre location or main laboratory.
5. All specimens are processed at the main laboratory (Edmonton). Testing requires 24 hours of incubation.
6. Results will be printed and sent by mail or fax. The client must indicate their choice on the requisition form.
Alternatively, the report may be picked up at the main laboratory (Edmonton) or at specific patient care
centre locations (Note: Reports will be held at the location for 7 days). If the result is faxed, no printed
results are mailed, unless requested.
7. Reports will indicate the presence or absence of coliforms and E. coli. The threshold for detection is
1 CFU/100 mL.
8. According to the “Guidelines for Canadian Drinking Water Quality” (Health Canada, December 2010):
 The maximum acceptable concentration of E. coli in private drinking water systems is none
detectable per 100 mL.
 The maximum acceptable concentration of coliforms in private drinking water systems is none
detectable per 100 mL.
9. The fee for this testing is $60.00 (includes GST), payable upon delivery of the specimen to the laboratory.
Make cheques payable to DynaLIFEDx.
10. Consultation with the on-call medical microbiologist is available upon request (780-451-3702 or
1-800-661-9876).
11. Please Note: If the water test demonstrates the presence of any coliforms, a copy of the report will
be forwarded to the local Medical Officer of Health.
DynaLIFEDx
Proprietary
Doc ID: MIC-FM-0005608
Revised: 06-Aug-2013