Name

Last Name

Email Address

Your Address. Street, town, or postal code.

Water Source Water SourceCityDrilled WellDug WellLake WaterOther

Water Problems Water ProblemsOdourTasteStainingBacteria & ContaminantsOther (if other)

Existing Treatment Existing Treatment Yes No

If yes, explain.

Comments or please expand on any area filled out as "other"