| Request for
General Information |
Request for Field Procedures |
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Company Name (if applicable) / Name: |
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Address: |
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City: |
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State: |
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Zip: |
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Phone
#: |
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Fax
#: |
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Email: |
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What
kind of well do you have? |
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What
is the production of the well normally in gallons per minute? |
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Has
that changed? |
Yes No
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Diameter of casing in inches: |
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Total
depth of well in feet: |
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Static Water Level in feet: |
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Well
screen type/length if applic: |
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Type
of formation: |
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For piping (buried or surface) to be
cleaned; |
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Diameter of pipe (in inches or mm): |
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Length in distance (feet or meters) of pipe to be
cleaned: |
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Type of pump to be cleaned: |
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Horsepower of Pump? |
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Your
perceived problem in well/system or physical symptoms noticed:
(ie., pump production down, slime or hard scale noted in piping system,
increasing concentrations of iron or manganese in water,
etc.) |
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Comments: |
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How
did you hear about our website? |
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