Master Well Owner Accomplishment Report
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Please fill out the following form to tell us about completed educational activities. Anything that you report using this form does NOT need to be reported on your annual accomplishment form. Thanks!

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1. Please provide your first and last name.

Please provide your first and last name.

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2. In what county of Pennsylvania did this activity take place?

In what county of Pennsylvania did this activity take place?

3. When did this activity occur?

	MM		DD		YYYY
Date of activity	When did this activity occur? Date of activity Month	/	Day	/	Year

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4. Approximately how many hours did you spend on this activity?

Approximately how many hours did you spend on this activity?

5. What type of activity did you accomplish (check all that apply)?

What type of activity did you accomplish (check all that apply)? Individual consultation

Presentation to a group

Table-top display use

Newspaper or newsletter article

Other (please specify)

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6. How many people were educated?

How many people were educated?

7. Please list email addresses for any contacts from this event. Separate the email addresses with a comma.

Please list email addresses for any contacts from this event. Separate the email addresses with a comma.

8. Please use this space to make general comments about this event, such as the group you talked to or the name of the event where you educated well owners.

Please use this space to make general comments about this event, such as the group you talked to or the name of the event where you educated well owners.

Master Well Owner Accomplishment ReportExit this survey >>

*1. Please provide your first and last name.

*2. In what county of Pennsylvania did this activity take place?