Assistance Request

The  Water Well Trust and members from the Water Systems Council created a rapid response program designed to help alleviate the immediate water access needs to homeowners as a result of natural disasters such as hurricanes and floodings.  

Please complete this form and the office will contact you once we receive your information.  

If you have questions, please call 888-395-1033.

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Name: *
Today's date: *
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Time
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Well Request Address, City, State and Zip code: *
Contact Address, City, State and Zip code: *
County of Well Request: *
Phone number:
Email address:
Are you the property owner?
 *
If no, Name of Property Owner
Do you have indoor plumbing?
 *
What is your need? *
Is the well for personal use? *
Is the well for emergency public relief? ie, church, fire department, etc. *
Is the property served by public sewer or private septic? *
If public sewer or private septic, is it functioning?
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If you do have a well but it is not functioning properly, please explain. *
Please provide a brief description of your water project including the well's intended use and who will be served by the well. *
Do you have a driller you have worked with or want to work with? *
If so, Who?
Do you have an estimate? *
Do you need financial assistance? *
If yes, how much? *
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