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Personal Water Evaluation Form

Below are the most common questions we need answered in order to properly assist you with solving your water problem(s). Please take a few moments and answer as many of the items you can. Once you submit the information to us, we will review the information and reply directly to you within one business day, either by e-mail or telephone. Thank you for the opportunity to help you!

When taking a sample of water for testing, please draw the sample of water towards the evening. Water samples that are taken first thing in the morning will be of water that has been setting overnight in your plumbing lines (or well casing if you are on a well), and could have a different testing level of dissolved substances than a water sample taken after water has been used during the course of the day.

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How many people are in the home?
How many full bathrooms are in the home?
What is the hardness level of your raw, unfiltered water?
* For the hardness value above, what measurement of unit applies? For the hardness value above, what measurement of unit applies?
GPG (Grains Per Gallon)
Parts Per Million
Milligrams Per Liter
What is the iron level of your raw, unfiltered water?
* For the iron value above, what measurement of unit applies? For the iron value above, what measurement of unit applies?
Parts Per Million
Milligrams Per Liter
What is the pH level of your raw, unfiltered water?
What is your flow rate in gallons per minute (GPM)? (See instructions below)

To determine your GPM using a 5-gallon container - take the container capacity in gallons, divided it by the number of seconds needed to fill container, then multiply times 60. The result is the GPM.

Example: Using a 5-gallon container it takes 45 seconds to fill the container. 5 gallons divided by 45 seconds times 60 = 6.66 GPM.

* Does the raw water have any color when it is first drawn? Does the raw water have any color when it is first drawn?
* Does the water have any odor? Does the water have any odor?
If there is an odor present, what does it smell similar to?
* Is the water clear when first drawn? Is the water clear when first drawn?
* If the water is clear when first drawn, does it turn color after setting overnight? If the water is clear when first drawn, does it turn color after setting overnight?
* If there is an odor in the water when first drawn, is it gone after setting overnight? If there is an odor in the water when first drawn, is it gone after setting overnight?
* Is there any sediment at the bottom of the container after the water sets overnight? Is there any sediment at the bottom of the container after the water sets overnight?
* Is there any slimy buildup at the water line inside your toilet tank? Is there any slimy buildup at the water line inside your toilet tank?
* Do you have iron stains on your plumbing fixtures? Do you have iron stains on your plumbing fixtures?
What is the size of the water line after the well pressure tank or public water supply?
* Are you on a Public Water Supply or a Private Water Supply? Are you on a Public Water Supply or a Private Water Supply?
Public Water Supply
Private Water Supply (with Jet Pump Installed Above Ground)
Private Water Supply (with a Submersible Pump installed down inside the Well Casing)
What is the Town, State & Zip Code where the order would be shipping to?
Comments. Please enter in the area below any additional comments you may have regarding the water problem(s) that you're
Please enter the telephone number where we can reach you:
Please enter the email address that we should respond to. You must enter your email address for a response to this form
Please complete the security math question 19-5
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