Created: September 2016

As part of the state's emergency response efforts to the drought, New Hampshire Department of Environmental Services (NHDES) is gathering information related to private well water availability and drought related economic impacts. The information requested in the below survey will assist the state in identifying the location and severity of drought impacts for assessing drought response needs.

Who should submit this form?

Households on a private well experiencing problems with water supply due to the ongoing drought or households that were experiencing problems, but made repairs to mitigate water supply issues. (This does not include homes on public water systems.)

Why is the information needed?
-To identify and assess drought response needs of individuals not served by public water systems.

-To identify where adverse impacts associated with drought are occurring.

-To quantify the specific economic impacts associated with drought to support potential disaster assistance requests.

Additional Information:
Collection of data is not to be construed as application for local, state or federal assistance.

NHDES intends to use this information for the reasons stated above.  Please note that information submitted to the NHDES is considered to be part of the public record.  NHDES will not publish your information, but other entities conducting Right-to-Know requests may be able to access the information you provide.

Thank you in advance for your time.

* 1. Contact Information

* 2. Please describe the water issue that you had/are having? (Check all that apply.)

* 3. What is the approximate date that the above problem started?


* 4. Has the problem been solved? (Check all that apply.)

* 5. If you tried to repair the problem, but the solution did not work, please describe what happened.

* 6. What was the cost of the repair?

* 7. Who completed the repair work?

* 8. What is the primary use of this well?

* 9. If the well is for household use, what type of household is the well supplying?

* 10. How many people live at the household?

* 11. What type of well do you have? (For well definitions, click here.)

* 12. Well Information: (If you do not know this information, please leave blank.  If your well was drilled after January 1, 1984, the below information may be found on the DES OneStop Data search.  Click on "Water Well" and type in street address information.

* 13. Well location: