Well Water Quality Disclosure Form
Property Information
Property Address
City
State
ZIP Code
Well Information
Type of Well (e.g., drilled, dug, driven, other)
Depth of Well (feet)
Location of Well on Property
Date Installed
Water Quality Testing
Date of Most Recent Test
Test Conducted By
Were contaminants detected? (If yes, list below)
Yes
No
If Yes, specify contaminants and concentrations
Other Issues/Findings
Disclosure & Certification
Seller’s Disclosure (Any known well problems, repairs, or restrictions):
Seller Name
Seller Signature
Date