First Name

Last Name

Phone

Email

Mailing Address

Street/PO Box

City

State

Zip

Pump Instalation Site

 

Same As Mailing Address? - Yes No

If "No" then please list address of pump site

Did H2O drill the well and/or set the pump? - Drilled Well Set Pump Both

If possible, what is the well tag?

Is hole dug for Pitless and Ditch dug to structure/home/pump house? - Yes No

Is pipe or wire already layed in ditch? - Yes No

If yes, then what size of wire Pipe

The pressure tank is in the - Pump House Basement Crawl Space

Is there power to the proposed control panel? - Yes No Don't have control panel for pump

Have mineral tests been done? - Yes No

Do you want water treatment equipment? - Yes No