Water Analysis Data Form

We’ll test your water for free!

We are not a city or regional agency. Our water test is free and there is no charge to the resident.

to have your water tested please:

• Fill out and send the form
• Run cold water for one minute
• Take a clean and well rinsed bottle, fill it 3/4 full and close tightly
• Keep the bottle handy and we’ll call to arrange a pickup time, normally the next morning
• If you prefer, drop the bottle off at our office; 10556 – 115 Street, Edmonton

Water Analysis Data Form

Date sample taken

What source of water do you have? City Private Well

Do you buy bottled water? Yes No

Do you filter your water? Yes No

Water sometimes has odour or tastes like: Chlorine Rotten Eggs Fishy Muddy Stale Metallic Bitter Salty

Does you water stain bath fixtures? Yes No

Do you experience dry itchy skin? Yes No

Are you a homeowner? Yes No

Number living in your home?

What age bracket are you in? 21-35 36-50 51-65 66+ Prefer not to say

Is drinking water quality important to you? Yes No

remarks

Resident Name

Address

Home phone number

Work phone number

Best time to call AM PM

Best time to pick up your water sample

* Type the numbers.