FOR Watershed Ground Water Survey

1. What is your water supply? [ ] Well, [ ] Spring, [ ] Public, [ ] Other

2. How deep is the well? _____________________________________________________

3. Are you concerned about the depth of your well? [ ] Yes [ ] No

4. What is the well=s storage capacity? ___________________________________________

5. What is the flow rate (gallons/minute)? 0-3 _____ 3-8 _____ 8-20 _____ 20+ ____

6. Has the flow rate changed in recent years? [ ] Yes [ ] No

7. What is your water pressure like? ____________________________________________

8. Are you having any supply problems? [ ] Yes [ ] No

9. Do you have good water quality? [ ] Yes [ ] No

10. When was the well last tested? _______________________________________________

11. What were the results? _____________________________________________________

12. Do you have sediment in your water? [ ] Yes [ ] No

13. Do you have a water treatment system? [ ] Yes [ ] No

14. If so, why are you treating your water? __________________________________________

15. Where is the water treatment system located? ___________________________________

16. What kind of treatment system is it? __________________________________________

17. How old is the treatment system? ____________________________________________

18. Who drilled/dug your well? _________________________________________________

19. When was your well drilled/dug? _____________________________________________

20. What is the well=s diameter? _________________________________________________

21. What casing material was used? ______________________________________________

22. How deep is the casing? ____________________________________________________

23. What repairs and maintenance have been done? _________________________________

________________________________________________________________________

24. How often have repairs been made? ___________________________________________

25. Who did the repairs? ______________________________________________________