If you would like more information concerning the quality of your water,
please fill out this survey and you will be contacted for a free water analysis.

Clean Water Specialists is not affiliated with city water or county health departments.

Name
Address
City
State
Zip/Potal Code
Phone Number
Best Time To Call
How would you rate the quality of your water?	--Select-- Unacceptable Poor Fair Good Excellent
Please tell us any conditions you may have experienced with your water:	Iron Stains Bad Smell Nitrates Bad Taste Cloudiness White Deposits
Do you live near any dumps or landfills?	--Select-- Yes No
When was the last time your water was tested?
Are you using any methods to filter or soften your water?	--Select-- Yes No
Do you buy bottled water?	--Select-- Yes No
Are you a homeowner?	--Select-- Yes No
Are you employed?	--Select-- Yes No
What age bracket are you in?	--Select-- under 13 years old 13 - 17 years old 18 - 25 years old 26 - 35 years old 36 - 45 years old 46 - 55 years old 56 - 65 years old Over 65 years old
Are you concerned about growing water pollution?	--Select-- Yes No