Well Submital Form

1

Please enter your information on the following screens

First Name

Last Name

2

Address* This field is required.

Street Address

City

Country

3

Township

4

Phone number

Area Code

Phone Number

5

Email

example@example.com

6

Preferred method of contact

Email

Phone

7

OwnershipPlease select if you own or rent your home.

8

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

9

Availability

Morning (9am - noon)

Afternoon (noon - 4pm)

Evening (4pm - 6pm)

10

Any water treatment (ex: UV or Chlorine Treatment, Do Not Include Softeners)?

YESNO

11

If yes, please explain:

12

Can outside tap be used?

YESNO

13

Explain where the outside "tap" is located

14

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

YESNO

15

Water source type?

16

If known, what is the depth of your well?

17

All submissions will be reviewed for eligibility. CCHD staff will contact you prior to sampling. Sampling will resume in the spring of 2023.

Questions? Please contact EHSD at 518-565-4870 or at health@clintoncountygov.com

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