Technical Needs Form

Company Name:

Address:

City:

State:

Zip Code:

Contact:

Title:

Telephone Number:

Fax Number:

Email Address:

Year Built:

Depth (in feet):

Diameter (in inches):

Screen Length (in feet):

Rock Well:

Type of Screen:

Filter or Gravel Pack:

Iron (mg/l):

Manganese (mg/l):

Total Hardness:

Total Alkalinity:

pH:

Calcium (mg/l):

Magnesium (mg/l):

Silica (mg/l):

Temperature:

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: