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:

Date Ordered:

Property Address:

City:

State:

Zip-Code:

Tenant's Name:

Tenant's Phone:

Sellers:

Address:

City:

State:

Zip-Code:

Phone:

Email:

Listing Agent:

Company:

Address:

City:

State:

Zip-Code:

Phone:

Email:

Buyers:

Address:

City:

State:

Zip-Code:

Phone:

Email:

Buyers Agent:

Company:

Address:

City:

State:

Zip-Code:

Phone:

Email:

Occupied?:

Power?:

Gate Code/Lock?:

Pets?:

Pump?:

Well?:
Old/New

Escrow Closing?:

Well Test including lab fees are:

Please Select One

$525.00 for 2hr test$650.00 for 4hr test

Location of well head:

Location of pressure tank:

Location:

Is there water filtration:
YesNo

**Payment is required at the time of test.Lab results and well report will not be released until payment has been made.We accept VISA and MASTER card.WE DO NOT BILL ESCROW.

*Individual Responsible for payment

Buyer orSeller

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