Well Water Sampling and Site Assessment

You are receiving this form because you are on a private or shared well in Benton County or Yakima County that could have a high level of nitrates in the water. While water is safe to drink with a low level of nitrates, high levels of nitrates in drinking water can be harmful to elderly people, pregnant people, babies, and people with certain health conditions.

After you complete this form, our contractor, Fulcrum Environmental Consulting will reach out to schedule a day and time to collect a well water sample to test for nitrates and conduct a well site assessment. Fulcrum Environmental Consulting's contact information is 509-907-3570 or YVWater@efulcrum.net. 

If you have any questions about this form, email us or call 360-236-3357.

 

1. Name:
 
2. Phone Number:
 
3. Email (test results will be emailed to you):
 
4. Address:
 
5. County:
Benton County  
Yakima County  
6. Do you rent the property?
Yes  
No  
7. What's the best way to contact you?
Phone  
Email  
8. If contacting you by phone is best, what is the best day and time (Monday - Friday, 8:00 a.m. - 5:00 p.m.) to call you?
 
9. 

What day and time of the week (Monday - Friday, 8:00 a.m. - 5:00 p.m.) are you generally available for us to come out and collect a well water sample and do a well site assessment? We will contact you to confirm an appointment.

 
10. How did you hear about this opportunity?
Mail  
Community Event  
Nonprofit Organization  
Word of Mouth  
Other:   
11. Agreement for Site Visit and Inspection
I agree to allow DOH staff or their contractor, Fulcrum Environmental Consulting, to inspect my well, take water samples, and measure my kitchen sink area for a potential reverse osmosis installation. The site visits will be pre-scheduled with me.