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Well Water Bacteria Test

  1. Collector/Sample Information (results are returned to this address)

  2. Include Area Code

  3. Owner Information (if different from collector information)

  4. Is the owner contact information different from the above?*

  5. Include Area Code

  6. Additional Information

  7. Bacteria Test Types

    There is a $13 fee for the bacteria test.

  8. Location

  9. Supply Type*

  10. Sewage Disposal*

  11. Construction Type*

  12. Payment Instructions

    To pay by credit card, submit this form. You will be prompted to enter payment information. After payment is processed, click the "Continue" button.
    To pay by cash or check, enter HDPAYLATER as the promotional code.
    Bring a printed copy of this form with the water sample.

  13. Leave This Blank: