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Private Well Registration

Register On Line

Your Full Name: (required)
Service Address: (required)
City: State: zip:
E-mail Address: (required)
Mailing Address (if different):

City: State: zip:
Phone Number (day):

Phone Number (night):

Depth of Well (ft.- if known):

Number of Well Points (if known):

Pump Horsepower (if known):

Year Well Installed (if known):

Use of Water (please select one):
Water Quality:
If Fair or Bad, Why?
High Salt
No Water
Other(comment below)
Other Comments: