Provide your mailing address and contact information.
Provide the location of the well.
Note: If the well location information is the same as above, you may skip this section and jump to "Well Construction Information" in this application.
If you have the following information, please provide it.
YES, I will participate in the Jefferson County Public Health private well water sampling program. I hereby grant my consent to allow my well water sample results to be analyzed by the Jefferson County Environmental Health program staff and the sample results and general location of my well to be published publicly in reports generated through this program. I understand that my personal information, such as my name, the location of my well, the address of my property, and/or the well permit number will not be disclosed to the public.
This field is not part of the form submission.
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