Fill out this form and upload drinking water well Nitrate (mg/L as N) results from a certified laboratory within the previous five years and completed as part of the Irrigated Lands Regulatory Program (ILRP) Drinking Water Well Monitoring Program. Drinking water well results with unsafe levels of nitrate (>10 mg/L-N) are eligible to receive free, safe drinking water.

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* 1. First name

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* 2. Last name

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* 3. Preferred language

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* 4. Phone number

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* 5. Email address

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* 6. What is your preferred way of contact?

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* 7. Address

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* 8. City

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* 9. State

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* 10. Zip Code

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* 11. Address type

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* 12. How many people currently live in your household? This will help us assess your drinking water needs.

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