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Water Questionnaire

In order for us to serve you better, please fill out the following questionnaire. You can submit the information at the bottom of the form and e-mail it to us. Or you can print it out, and and fill it in and bring it with you with your water sample. If you don't know the answer to any question, please feel free to leave it blank. To print out the blank form in PDF. format, click here.
If you don't have Adobe Acrobat Reader, you may download it here.

Name: Phone:


Town: Zip:

Billing Address: Town: Zip:

Do you have a current water treatment system in place?: Yes No

If so, check all that apply:
Water Softener: Iron Filter: Acid Neutalizer: Cartridge Filter:
Radon System: Arsenic System: Carbon Filter: UV Light:


If so, when was it installed:

Who installed it?:

Is your water staining your fixtures?: Yes No

If so, what color is the staining?:
Orange: Black: Blue: Green: Brown:

If you lift off the back of the toilet tank, what color is the water?:

Is your water staining your laundry?: Yes No

Does your water smell?: Yes No

If so, Does it smell like:
Metal: Rotten Eggs: Musty:

How old is your house?:

How many bathrooms?: How many people in the house?:

Do you have a full basement?: Yes No

Is there a floor drain?: Yes No

Do you have a jet pump or a submersible pump?:

What kind of pipes are in the house? (check which one applies):
1/2" Copper: 3/4" Copper: 1" Copper: Plastic/Pex pipe:

Other Comments:

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