Home Owner Questionnaire

Wilkes University / CCGG Water Testing Program
Dear Private Well Owner:
The Carbon County Groundwater Guardians (CCGG) and Wilkes University formed a partnership to provide a
water-testing program, which benefit homeowners by providing an easy and affordable way to test their
drinking water.
The Center for Environmental Quality at Wilkes University runs a state-of-the-art water-testing laboratory that
can be used by homeowners with private wells. Mr. Brian Oram, a Professional Geologist, is the Director of the
Drinking Water Testing Laboratory.
Mr. Oram is offering discounted prices on water testing when they are ordered through the Groundwater
Guardians. The lower cost is possible because the Groundwater Guardians do all the paperwork and billing
which saves time and money for Wilkes University. You do not need to live in Carbon County to take
advantage of this program.
You will be asked to fill out a short questionnaire that is designed to provide Mr. Oram with specific
information about your well. This will allow him to make a recommendation as to what testing you should do
thus eliminating unnecessary testing. Of course you are free to choose the testing options you want.
The test results will be sent directly to you. If any result is above the Maximum Contaminate Level (MCL) you
will receive specific advice on what this means and recommendations on what you can do to be safe.
We don’t sell water treatment devices and we don’t recommended them unless necessary. Many conditions can
be solved without them. If you feel you want to install treatment devices, you will know exactly what you need.
Wilkes University and the Groundwater Guardians are both nonprofit organizations and there will be no bias in
the recommendations.
All information obtained by Wilkes University and the Groundwater Guardians will remain strictly confidential.
It will NEVER be released to anyone without your written permission.
Yours truly,
Carbon County Groundwater Guardians

Thank You for Your Interest in OUR Groundwater

Home Owner water testing options

1. Your Name(required)
2. Email(valid email required)
3. Street Address(required)
4. City or Town(required)
5. State(required)
6. Zip Code(required)
7. Daytime Phone (include area code)(required)
8. Evening Phone (include area code)
9. What county do you live in?(required)
10. What township or municipality do you live in?(required)
11. Are you satisfied with your water?
12. Yes No
13. Do you drink your tap water?
14. Yes No
15. Do you have any of the following problems with your water?
16. Cloudiness Odor Taste
    Fine Particles Dirty water after a heavy rain? Stains in sink or tub/shower?
    Crust formation on faucets? Stains in pots after boiling?
17. List any other water problems here:
18. What type of water supply do you have? Drilled Well Dug Well Spring Stream Other Municipal
19. If water supply is municipal, list name of water company:
20. If water supply is "Other", describe here:
21. If you are not on a municipal system, is your well at least 100 feet from the septic drain field?
22. Yes No
23. If you have a well, supply as much information about it as possible:
24. When was the well installed?
25. Name of well driller
26. Do you have any specific design information about your well?
27. Yes No
28. Do you have a copy of the well driller’s well log?
29. Yes No
30. How deep is the well?
31. What is the well flow rate (gallons/minute)?
32. What is the depth of the casing in the well?
33. What is depth to standing water?
34. What type of septic system do you have?
35. Cesspool Septic Tank
    Mound System Other
36. If Septic System is "Other", describe here:
37. How old is your septic system?
38. When was the septic system last pumped? (Date)
39. Are there, or were there, any sources of groundwater contamination within 1 mile of your well?
40. Factories Gas stations
    Farms Landfills
    Mining operations Cemeteries
    Other
41. If Other, please explain
42. Have you ever had your water tested?
43. Yes No
44. If you have had your water tested, enter date and name of tester.
45. If you have had your water tested, were there any problems found? If "yes", describe below.
46. Yes No
47. If you answered "yes" to previous question, descibe problem here.
48. If you have any treatment devices on your water system now, descibe here:
49. LIST ANY SPECIAL CONDITIONS OR CONCERNS YOU MAY HAVE HERE:
50. Please indicate here the testing package option that you are interested in.
51. OPTION 1 - BASIC WATER CHEMISTRY PACKAGE OPTION 1b - Includes CCGG OPTION 1 plus Arsenic and Lead
    OPTION 2 - THE BASIC WATER BACTERIAL PACKAGE OPTION 3 - NUISANCE BACTERIA
    OPTION 4 - COMPLETE WATER TESTING OPTION 5 - PATHOGENIC SCREENING, STANDARD PLATE, TOTAL COLIFORM
    OPTION 6a - FIRST FLUSH COPPER AND LEAD ADDED TO OPTION 1 or 1b OPTION 6b - FIRST FLUSH COPPER AND LEAD
    OPTION 6c - SULFUR WATER TESTING
    
    
52. RELEASE TO THE CARBON COUNTY GROUNDWATER GUARDIANS.
53. Yes - I agree to release results to CC Groundwater Guardians No - I do not want my test results released.
54. Would you be interested in attending workshops related to any of the following topics?
55. Groundwater and Water Wells Water Conservation
    Septic System Operation and Maintenance Hazardous Chemicals and Recycling
    Other topics (describe blow)
56. If you checked "Other", describe workshop you have an interest in attending.
57. Would you like to be on CCGG’s Mailing List?
58. Yes No
59. Would you be interested in joining CCGG?
60. Yes No

 

cforms contact form by delicious:days