Your name and email address:

Block Number:

Lot Number:

Please check all the applicable boxes and fill in the blanks as appropriate.

A well has not yet been constructed on this lot.

A well has been constructed but the home has not yet been built.

The home was unoccupied and no water was used during the reporting period.

Water was used during the reporting period and the meter reading data is as follows:

Meter Reading:                                    Meter Read on Date (mm/dd/yy):

                   

How would you describe your outdoor water use during the reporting period?

1. None
2. Occasional cleaning uses and/or hand-watering of plants & shrubs
3. Hand-watering of lawn*
4. Regular watering of lawn with underground sprinkler system*    

*For choices 3 and 4 above, please estimate your total watered lawn area:

square feet

When was the construction of your well completed (mm/yy)

When was your residence first occupied (i.e., regular water use first began) (mm/yy)

When was your well meter installed (mm/dd)

Where is your well meter located?