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Water Testing Questionnaire
Name
Address
Email Address
Phone Number
Do you receive your water from a private well?
Yes
No
Was your home constructed prior to 2014?
Yes
No
Do you have copper pipes in your home?
Yes
No
Do you have any stains in your toilet? Are they:
Brownish or Blackish
Reddish or Orangish
Bluish
Pink
None
Does your water have a metallic taste?
Yes
No
Do you have scaling/spots on any of your glassware?
Yes
No
Is corrosion observed on metal plumbing fixtures?
Yes
No
Is there a rotten egg odor in the cold-water?
Yes
No
Is there a rotten egg odor in the hot water only?
Yes
No
Is it difficult to remove soap build-up in your bathtub?
Yes
No
Do you live in an area where homes have underground oil tanks?
Yes
No
Do you live within a ¼ of a mile of any of the following?
A gas station or any type of fueling station?
An industrial complex?
An orchard?
A nursery or farm that applies herbicides?
A nursery or farm that applies pesticides?
Are you concerned that your well may have had exposure to Roundup?
Yes
No
Does the air in your home have elevated levels of radon?
Yes
No
What county do you live in?
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