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Private Well Water Testing Application

  1. Disclaimer

    Information submitted on this form will be sent via unsecured email. To protect sensitive information, do not enter the following items or similar information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, credit card numbers, medical information, passport numbers, and passwords. Please review our privacy policy located at By submitting this form, you acknowledge and accept the terms listed in the privacy policy.


    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.

  6. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
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  8. This field is not part of the form submission.