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 Comments