Private Well Registration
Name
*
First Name
Last Name
Service Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Depth of Well (in feet – if known)
Number of Well Points (if known)
Pump Horsepower (if known)
Year Well Installed (if known)
Use of Water
*
Irrigation
Geothermal
Drinking Water
Water Quality
Good
Fair
Good
If Fair or Bad, why?
High Salt
Iron
No Water
Odor
Other
Other Comments
Under Florida Statute 119 (Public Records) your email communications may be subject to public disclosure.
*
Submit
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