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Free Water Test Anaylsis

 
Water Analysis Form
Water Anaylsis Form
Name: Date:
Street Address: City:  
State:   Zip Code:
Phone: E-Mail Address:
       
1. Water Source:
  City or area-wide authority
  Community water system (small water system usually supplying 12 homes or fewer)
Water Comes From:  
  Well Reservoir
  Lake River
  Unknown  
  New private well - approx age months
  Old private well - approx age months
  Private Lake Private Spring
  Private Dugover Private Cistern
  Other - Describe:
       
2. Household Information - Do you now have water conditioning equipment?
  No Yes
  Type
  Size
  Single Family  
  Multi-Family No of Units:
  Number of Persons Number of Baths      
  Lawn irrigation on water system
  Indoor Pool Outdoor Pool
  Capacity: gallons
  Water line size from source: inches
       
3. Water System
  Type of Pump  
  Piston   Jet      
  Submersible   Unknown      
  Pumping rate of pump gpm
       
  Pressure Tank  
  Air to water Bladder capacity gallons
  Operating pressure (low/high) / psi
       
4. Water Problems
  When this sample was drawn, it was:
  Clear Colored
  Cloudy  
  This water sample is:
  Untreated Treated
  How is it treated?      
       
Problems
  hardness (e.g. high soap usage, bathtub ring, lime deposits, etc
  Iron Deposits - if so, is iron build-up in flush tank? yes no
  Greasy Gritty Stringy (iron bacteria?)  
     
  Color of Water Greenish or blue stains Red Orange Black
  Pitting of fixtures and/or pipes
  Sand (visible particles) Sediment or silt (cloudy)
  Bad Taste  
  Iron Bitter Taste
  Salty Taste Other:
  Bad Odor  
  Rotten Egg Musty Odor Iron Odor      
  Odor is in  
  Cold Water Hot Water Both  
  Other Odor Problems: Describe:
       
 

Return Completed Form with Water Sample to:
Glass water Systems Inc.
5130 S. Dale Mabry
Tampa, Florida 33611
or email to glasswatersystems@msn.com
Water Analysis Form
 
 
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