tt | Pumpco

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

$550.00 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 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.WE DO NOT BILL ESCROW.

*Individual Responsible for payment

Buyer orSeller

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