Groundwater Contamination Assessment Questionnaire

Respondent Name

First NameMiddle NameLast Name

Organization or Site Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Site Location / Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Groundwater Source Type

Assessment Date

Date

Suspected Contamination Concern

Observed Signs of Contamination

Estimated Concern Level

Potential Contamination Sources Near Site

Current water-use status

Well depth or water source depth (if known)

Recent changes observed in water quality

Describe any odor, color, or taste observations

Has any prior water testing been done?

Preferred Follow-up Method

Sample Testing Status

Notes for Reviewer

Additional Comments