Glenwood, Pope County 2026 Well Water Screening Registration Form
Please fill out this form for each well you wish to have screened for water quality.  Please stay (10-15 minutes) to learn about your screening results. If you cannot stay, provide a valid email address to get your results. If you do not provide an email, please provide your phone number or address. All data will remain confidential. See our Data Practice Policy  here.
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First Name
(Optional Question)
Last Name
(Optional Question)
==== Either Email or Phone Number is required so we can email you a copy or call you about your screening results  |  Email Preferred ====
Email *
(Required Question) Please provide an email address for us to have a way to reach you with results.
Phone Number
Please provide a phone number if not providing an email address (see previous question).
Address
City State Zip (Optional Question)
Township *
(Required Question)
County *
Pope
Event Outreach *
(Required Question)  How did you learn about this event? Check all that apply. 
Required
Followup

  1. Are you interested in receiving follow-up information/consult about results or your well? If yes, be sure to include email or phone number at top of form.  (Optional Question)

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Primary Drinking Water *
 (Required Question) The sample is from a well that is your primary drinking water source?
====  All following questions are optional but if answered they may help our consultants interpret your screening results   ====
Sample Source
Where did you take the sample from? (Optional Question)
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Last Well Test
Last time your well was tested? (Optional Question)
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Well Information
Do you have a well record or well construction information? (Optional Question)
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Well Age
How old is your well (leave blank if unknown). (Optional Question)
Well Depth
How deep is your well (leave blank if unknown). (Optional Question)
Well Concerns
Do you have any concerns about your drinking water? If yes, check those boxes below. You can also add additional concerns in the "Other" box: (Optional Question)
Child Well Use
Do young children (less than 6 months old) drink this water frequently? (Optional Question)
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Water Treatment
Type(s) of conditioning or treatment system you have? (Optional Question)
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