Order Well Test NOTE: “There will be a $125 charge if there are locked gates or locked well houses that the technician can not access” Person Ordering Test: Test Date Preference: Property Address: City: State: Zip-Code: Tenant's Name: Tenant's Phone: Date Ordered: Individual Responsible for Payment*? *$35 Per Hour Generator Fee Occupied?: Gate Code/Lock?: Power?: Pets?: Well Location: Is Equipment Accessible? Is there a Pump in the Well? Water Filtration in Place? Location: Listing Agent: Company: Address: City: State: Phone: Zip-Code: Cell: Email: Sellers: Address: City: State: Zip-Code: Phone: Email: Buyers Agent: Company: Address: City: State: Phone: Zip-Code: Cell: Email: Buyers: Mailing Address: City: State: Zip-Code: Phone: Email: Select One: 2 Hour Test $550 4 Hour Test $650 Optional 2 Day Lab Processing $90 OTHER LAB OPTIONS Arsenic: Lead: Standard $40 $40 2 Day $80 $80 Nitrite: Nitrates Standard $60 $60 2 Day $120 $120 Payment is required prior to the test beginning. If payment is not secured, test may be rescheduled until payment has been made. Lab results and Well report will not be released unless invoice is paid in full. If production test cannot be performed due to faulty equipment, customer will be issued a refund less a $125.00 Service call and Labor at $95.00 per hour. 24 Hour Cancellation Notice is requested. Cancellations within 24 Hours may be subject to $125.00 Fee. We accept All Major Credit Cards. Invoice can be paid safely and securely with our online processing or by calling our office. Payment can also be made directly to the technician at the time of test. Due to Unpaid Invoices, We No Longer Bill Escrow Accounts Notes: Test Date: Technician: Invoice #: Date Paid: Report Sent: Lab Report Sent:
