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Free Well Water Test Kit Form

Please fill out as completely as possible. To receive your free test kit we do need a complete address and your email address. No salesman will call and we never sell or give away your personal information.

Contact Info
Name:
Mailing Address:
City: State:
Zip/Postal Code: Country:
E-mail:  
Water Source Information (check all that apply). If this is for your home please tell us either your well water flow rate or at least the number of bathrooms you have which will help us in sizing a systems for you if you need any recommendations:
Private Well Shared Well Spring River / Creek
Lake Cistern I do not know
Well water flow rate in gallons per minute: How can I find this out?
Number of bathrooms in home:
Water Quality Concerns (check at least one):
Red/Orange stains Brown stains
Black stains Blue stains
White spots/scale Corrosion
Bad tastes Bacteria
Parasites Iron
Manganese Chemicals
Nitrate Salt water
Heavy metals Sediment
Color
Cold well water has sulfur odor
Only Hot water has sulfur odor
Sulfur odor in Both Hot and Cold
Other odors that are not sulfur
Other Problems
 
 
Please tell us background information here. This is an important area where you can tell us what your main concerns are and any priorities you have regarding your water!
Disclaimer:
These water test kits are provided at no cost for educational purposes and are not meant to provide a certified water analysis. Results can vary. Clean Water Systems Inc. neither accepts or assumes any liability associated with the test kits or recommendations based on the analysis. No warranty or guarantees are extended. I agree to hold harmless Clean Water Systems Inc for any information contained herein and take full responsibility for my own water systems and applications.
I agree I do not agree

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