Well Water Test Kit Order Form

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*These fields are required.

Contact Information
First Name *
Last Name *
Email *
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. This will help us in sizing a system for you if you need any recommendations:
Water Source *	Please select onePrivate Well Community Well Spring River / Creek Lake Rainwater Other Don't Know
Number of Bathrooms	Please select one1 1.5 2 2.5 3 3.5 4+
Well Flow Rate in Gallons Per Minute
Red / Orange Stains	Yes No
Brown or Black Stains	Yes No
Blue Stains	Yes No
White Spots / Scale	Yes No
Sediment	Yes No
Color in water	Yes No
Sulfur odor in cold well water	Yes No
Sulfur odor in hot water only	Yes No
Water has other odors	Yes No
Corrosion	Yes No
Please give us as much background info as you wish so we can learn more about your concerns or goals regarding your water quality:
The Usual Disclaimer:
These water test kits are provided 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. Yes No
Subscribe to the Clean Water Report while you are here and receive coupons for $25 on future purchases at the Clean Water Store! Yes:
Satisfaction guaranteed or your money back!