Assessment form test page

Eligibility Questions

1. Do you live on the property where the well is located?*

Yes
No

2. Do you rent or own?*

Own
Rent

2. b. Did the owner give you permission for the well assessment?*

Yes
No

3. Do you use or plan to use the well for drinking water?*

Yes
No

4. Is the well used for agricultural purposes?*

Yes
No

5. Have you ever had an RCAC well assessment?*

Yes
No

6. Is the well above ground and accessible for the assessment?*

Yes
No

Thank you for your interest in the well assessment. Unfortunately, you are not eligible. Please email Thi Pham at tpham@rcac.org if you have any questions.

Contact Information

Name*

First Last

Address*

City*

State*

County*

We are currently conducting well assessments in certain California and Idaho counties. See the shaded areas on the service area map. Locations are within a 60 mile radius of Chico, Sacramento, Fresno and Bakersfield in California and Boise, ID. If you are located outside the service area, you are not eligible for the well assessment at this time. If you would like us to notify you when we expand the well assessment services to other areas, please join our mailing list.

You are not eligible at this time and will not be able to submit this form. If you would like us to notify you when we expand the well assessment services to other areas, please join our mailing list.

Zipcode*

Email*

Phone*

Secondary Phone

How did you hear about the program?*

Please specifiy other*

Well Assessment Request

Eligibility Questions

Contact Information