Drinkwell Treated Water Quality Report Submission Form
Full Name
*
First Name
Last Name
Well ID
*
Well Operated By
*
Village
*
District
*
State
*
Country
*
PIN Code
E-mail
*
Phone Number
*
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Area Code
Phone Number
Name of Organization providing Water Quality Report
Date Water Sample Collected from Site
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Month
-
Day
Year
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Date Water Sample Received by Testing Lab
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Month
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Day
Year
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Date Water Quality Report provided by Lab
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Month
-
Day
Year
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Cost of Water Quality Report
Arsenic (As) in mg/L
Iron (Fe) in mg/L
Manganese (Mn) in mg/L
Fecal Coliform in cfu/100ml
Fluoride (F) in mg/L
pH
TDS in mg/L
Calcium (Ca) in mg/L
Alkalinity
Nitrate
Hardness
Silica
Sodium (Na) in mg/L
Conductivity
Turbidity
Magnesium (Mg) in mg/L
Upload Treated Water Quality Report (pdf or jpeg)
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