Name, Address, Property #

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* 1. Name, Address, Property #

Is your well for domestic use only? YES or NO. If YES, Number of residents in the house? If NO, what are your non-domestic uses and what quantity of water is used each day?

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* 2. Is your well for domestic use only? YES or NO. If YES, Number of residents in the house? If NO, what are your non-domestic uses and what quantity of water is used each day?

Well Type (bedrock, dug, driven point), Well Driller (Company)

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* 3. Well Type (bedrock, dug, driven point), Well Driller (Company)

Date Installed, Well Depth _____ ft. Well Diameter ____ Inches Casing Depth _____ft.

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* 4. Date Installed, Well Depth _____ ft. Well Diameter ____ Inches Casing Depth _____ft.

Estimated Yield (gallons per minute if tested), Estimated Water Depth ____ft. Pump Size ____ HP Pump Depth ____ ft., Estimated Depth to Bedrock _____ ft.

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* 5. Estimated Yield (gallons per minute if tested), Estimated Water Depth ____ft. Pump Size ____ HP Pump Depth ____ ft., Estimated Depth to Bedrock _____ ft.

Is treatment required for your well: YES or NO If Yes - List water treatment equipment

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* 6. Is treatment required for your well: YES or NO If Yes - List water treatment equipment

Describe the most recent maintenance performed on your well or pump

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* 7. Describe the most recent maintenance performed on your well or pump

Would you support a Water Supply System for the Village of Cardigan?

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* 8. Would you support a Water Supply System for the Village of Cardigan?

If Yes: How would you like to pay for the system

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* 9. If Yes: How would you like to pay for the system

What is the maximum you would be willing to pay per month to have a central water service? $__________

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* 10. What is the maximum you would be willing to pay per month to have a central water service? $__________

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