Well Submital Form

1

Please enter your information on the following screens

First Name

Last Name

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2

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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3

Township

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4

Phone number

Area Code

Phone Number

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5

Email

example@example.com

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6

Preferred method of contact

Email

Phone

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7

If you chose "Other" for method of contact - Please explain

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8

OwnershipPlease select if you own or rent your home.

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9

NOTE: If you rent and are concerned about your water quality, please complete a nuisance complaint form here:

http://www.clintonhealth.org/forms/nuisance%20complaint%20form.pdf

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10

Availability

Morning (9am - noon)

Afternoon (noon - 4pm)

Evening (4pm - 6pm)

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11

Any water treatment (ex: water softener, UV light, water filter, etc.)?

YESNO

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12

If yes, please explain:

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13

Can outside tap be used?

YESNO

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14

Explain where the outside "tap" is located

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15

Are there any children in the household that are under 6 months?

YESNO

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16

Water source type?

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17

Please explain, if you chose "other" for water source type

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18

If known, what is the depth of your well?

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