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Name
Email
Address
City
Phone number
What type(s) of well are you interested in sampling?
Domestic
Irrigation
Stock
Other:
Do you own or rent the property?
Own
Rent
Other:
Would you prefer your well shown as a point on the map or obscured within a colored township (6 mile x 6 mile square)?
I am OK with showing the location of my well on the map at its exact location (single point)
I prefer to have my well shown as somewhere within the township
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