Drinking Water Survey

Questionnaire

Introduction: The Paul Smith's College Adirondack Watershed Institute is conducting a survey of private drinking water wells in the Adirondack Park to assess the extent and magnitude of contamination of drinking water by road salt. Your participation in this survey is important for supporting regional efforts to both understand and manage the impacts of road salt on environmental and human health. Everyone who completes this survey will have their well water tested at no cost through generous financial support from AdkAction, Cloudsplitter Foundation, and The Fund for Lake George. All participants will receive copies of their water test results as well as the results of the entire survey. Please contact Dan Kelting (dkelting@paulsmiths.edu) If you have any questions about this survey.

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* 1. Would you like to continue with this survey?

Yes

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* 2. Address

Name

Address

Address 2

City/Town

ZIP/Postal Code

Email Address

Phone Number

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* 3. What year was your well installed?

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* 4. How deep is your well in feet?

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* 5. How was your well constructed? (select all that apply)

Point well

Dug well

Drilled well

Cased well

Uncased well

Screened well

Unscreened well

Fracked well

I don't know

Other (please specify)

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* 6. What kind of formation does your well tap into? (e.g. granite bedrock, gravel, confined aquifer, unconfined aquifer, etc.)

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* 7. What water treatment systems do you have? (select all that apply)

Reverse osmosis

Water softener

Carbon filter

Other filter/membrane

Chlorinator

Ultraviolet

None

Other (please specify)

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* 8. How would you describe you well's water quality? (e.g. taste, color, odor)

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* 9. Do you have any well water test records that you'd be willing to share with us?

Yes

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* 10. May we obtain the location of your well using a GPS unit?

Yes