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Residential Survey <br /> Name of Property Owner: <br /> Address of Property: <br /> Name of Person Responding to Survey: <br /> Phone Number: Date: <br /> Owner E] Renter F <br /> How long have you resided at this address? <br /> 1. Is your property connected to a public water supply? Yes ❑ No ❑ <br /> 2. Do you have any wells located on your property? Yes ❑ No ❑ <br /> a. What is the well used for? (You may circle more than one) <br /> a. Drinking water <br /> b. Showering/ bathing/ hand washing <br /> c. Irrigation <br /> d. Other: <br /> b. Do you have any well construction information Yes ❑ No❑ <br /> (depth,pump hype,etc.)? <br /> c. Do you know the name of the company that drilled the well? Yes❑ No ❑ <br /> d. Do you know when the well was installed? Yes❑ No ❑ <br /> e. Is the well currently operable? Yes❑ No ❑ <br /> f. Do you know where the well is located? Yes ❑ No ❑ <br /> Please describe its location: <br /> g. Do you have any testing results on the well water? Yes ❑ No❑ <br /> Please provide the completed form to CRA or return in the stamped envelope provided. <br /> Thank you for your time. <br />