Wufoo
Well Water Treatment Recommendation
Thank you for considering PuriTec for your water treatment needs. Please answer the following questions as best you can. We will respond within 1 business day. If you have any questions please call us toll free at 1-888-491-4100. All information is kept confidential and is never shared.
Water Type:
*
Municipal/City Water
Well Water (Private Well)
Well Water (Community Well)
Unsure
Other (please specify)
If Well Water, do you have a pump?
No
Yes - a Jet Pump (on the ground)
Yes - a Submersible Pump (in the well)
Unsure
Do you know your Gallon Per Minute Flow Rate? If yes, please indicate:
Do you see brownish, reddish or orange stains in sinks, tubs and toilets?
Yes
No
If you know the level of iron in your water, enter it here:
Do you see white scale or build up around plumbing fixtures or in toilets?
Yes
No
If you know your water's hardness level, enter it here: (Please indicate if gpg, mg/l or ppm.)
Do you detect any odor in the water?
Chlorine
Sulfur
Musty Odor
None
Other
If you answered "Yes" above, how often do you notice it?
Always
Occasionally
Almost Never
Not Applicable (no odors detected)
If yes, where do you detect the odor mostly - on cold water or hot?
Cold Water Only
Hot Water Only
Both Hot & Cold Water
Not Applicable
Do you see any black stains in the tub, sink or toilet? If yes, is it "slimy"?
Yes, and it is NOT slimy
Yes, and it IS slimy
No
If known, what is the pH of your water?
How would you describe the appearance of your water?
Clear
Brown
Red
Milky
Other
If you answered "Yes" to above, how often does your water have that appearance?
All the time
Mornings Only
Occasionally
Not Applicable
How many bathrooms are in your home?
Do any of your showers have power jets in them?
Yes
No
Unsure
Total number of people living in your home:
Please add any additional information which may be helpful or any specific concerns you have e.g. existing equipment installed, known bacteria present, or general questions.
Name
*
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
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Andorra
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Canada
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Central African Republic
Chad
Chile
China
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Comoros
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Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
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Dominica
Dominican Republic
East Timor
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El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
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Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
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Hungary
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India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
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Kenya
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North Korea
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Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
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Turkey
Turkmenistan
Tuvalu
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Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country
Phone Number
*
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Email
*
Preferred Contact Method:
Email
Phone
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