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?
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?
If yes, where do you detect the odor mostly - on cold water or hot?
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?
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 Country
Phone Number * ### - ### - ####
Email *
Preferred Contact Method:
Email Phone
Do Not Fill This Out