2025 Powhatan Well Water Testing Clinic

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

*Note: DUE TO LIMITED SUPPLIES THIS YEAR, POWHATAN RESIDENTS WILL BE GIVEN PRIORITY FOR WELL WATER TEST. If you are from another county please try to find another well water clinic near you or fill out this form and you will be put on a waiting list base off of the order of those who applied.

Sample Kit Pick Up: Tuesday, October 7, Powhatan Extension Offices listed below (8:30am-6pm). If unable to come during office hours, please make arrangements with staff for pickup after 5pm by calling (804) 598-5640.

Sample Return: Wednesday, October 8, between 7am and 9am at either location listed below:

Powhatan Extension Office

3910 Old Buckingham Rd.

Powhatan, VA 23139

Please fill in the blanks below and complete your registration. Payment must be received to prior to participation in this program.

If paying by credit card, fill out registration form and we will send you a link to our online payment portal.

First Name *

Last Name *

Phone Number *

Are you a Powhatan resident

Yes

Clear selection

Address *

Clear form

Never submit passwords through Google Forms.

This form was created inside of Virginia Tech.

Does this form look suspicious? Report

Forms