Please print this form, fill it out, sign it, and mail to the address below

Well Survey

Please Circle or Write In Response:
1. How many wells are on your property? 0 1 2 3 _

(If "0", you are done with the survey. Thanks for your input.)

2. Age of well(s)? __________________years "Don't know"
3. Depth of well(s)? _____________________ft "Don't know"
4. Depth of water table? _____________________ft "Don't know"
5. What kind of pump(s)? Submersible Jet "Don't know"
6. Depth of pump(s)? _____________________ft "Don't know"
7. Has water table lowered? Yes (by ______ft) No "Don't know"
8. Lowered pump because water table dropped? Yes (by ______ft, when:_______) No
9. Drill new well(s) because water levels dropped? Yes (How deep? ________ft) No
10. Problems with water quantity? Yes No "Don't know"
11. Overall water quality? Great Good Fair Poor Terrible
12. Ever have problems with bacterial contamination? Yes No "Don't know"
13. Excess iron (over 0.3 mg/L)? Yes No "Don't know"
14. Hardness? Soft Moderate Hard "Don't know"
15. Hydrogen sulfide (rotten egg) smell? Yes No
16. Have you tested the water quality? Yes No
17. Do you rely on a well for daily household use? Yes No
18. Do you rely on a well for agricultural use? Yes No
19. Would you be interested in participating in a program to monitor water levels and/or water quality in private wells in Penngrove? Yes No Maybe

Property Owner's Name:
Property Address:
Phone Number:

Signature of Property Owner: _______________________________________

Additional Comments:

Please Return To:
John King
P. O. Box 127
Penngrove, CA 94951
Phone: 763-7023