Request for Information / Quote Request

Subsurface Technologies, Inc.

The following information is requested for Aqua Freed® Well Rehabilitation and Aqua Gard™ Well Maintenance.

RFQ

Contact Information

Company Name

*Address

*City

*State

Country

*Zip Code

Contact Name

Contact Title

*Email Address

*Telephone Number

Fax Number

Well Number

Well Construction Information

Year Built

Depth (in feet)

Diameter (in inches)

Screen Length (in feet)

Rock Well

Type of Screen

Filter or Gravel Pack

Water Chemistry Information

Iron (mg/l)

Manganese (mg/l)

Total Hardness

Total Alkalinity

Calcium (mg/l)

Magnesium (mg/l)

Silica (mg/l)

Temperature

Additional Information

Original Production

Current Production

Geological Information

Previous Down Hole Videos

Please describe any applicable well and pump history, description of past rehabilitation efforts and results