Participation Form – Southwest Nature Park

1. Name

First

Last

Physical Address

Please provide the HOMEOWNER’S contact information and let us know the preferred contact method so we may contact you prior to sampling to confirm.

Home Phone

Cell Phone

May we text you?

Yes
No

Email

2. Do you want your well sampled? If yes please continue to the next question. If no, please submit this form.

Yes
No

3. Have you had your well tested before?

Yes
No

a. If so, for what analyses (hardness, iron, manganese, sulfur, etc)?

b. When was it last tested?

c. Would you be willing to share those results? Please note, due to Florida’s public records law, the results may become public information, if shared.

Yes
No

d. How often do you test your well?

4. Sampling will be performed February 26-29 and March 11-14, 2024. The sampling will take approximately one hour or less. Please indicate which days you are available to either collect a sample and leave it outside for pick-up or have a team member visit your property to collect a sample. After reviewing responses to the questionnaire, the team will coordinate with you on what days are available for sampling.

5. Please describe the closest point to your well where water can be collected (e.g. spigot, valve)?

a. Is the sampling point inside or outside the house?

Inside
Outside

6. Is there a water treatment system upstream of (before) the sampling point (e.g. softener, reverse osmosis, ion exchange, etc.)? If so, what type of system?