Well Test Order Form

INSTRUCTIONS: Please fill out the form ONLINE print it, and sign it in the spaces provided at the bottom of the last sheet. After you have printed and signed the form, return it by fax to 1.831.663.3590. Upon receipt of the form, completed with the authorization signature, you will be called usually within 24 hrs. to confirm your appointment. Our goal is to provide the best possible service to you so please take the time to complete as much of the information as possible.

Ordered By:

Date Requested:

Phone No.

Are you a Real Estate Agent?

Yes

(If Yes) Lic. No.

BUYERS INFORMATION:

Name:

Address:

Phone No.

Ext.

Fax No.

REAL ESTATE COMPANY:

Name:

E-Mail:

Address:

City:

State:

Zip:

Phone No.

Ext.

Fax No.

SELLERS INFORMATION:

Name:

A.P.N. No.

Address:

City:

State:

Zip:

Well Location: (If different from above)

Address:

City:

State:

Zip:

Water System Information:

Water System Name:

No. of Users

Standard 1 hr. Inspection (no samples)

$400.00

Standard 1 hr. Inspection(Bacteria and Nitrate)

$460.00

Other

Sounding Tube Installation

$700.00

Additional Water Quality Tests (Call for Pricing)

NOTICE:

Any of the above listed inspection options may not produce the results you want because of the inaccessibility of the well casing. Installing a dedicated sounding tube may allow a greater amount of data to be collected. If water level measurements are needed sounding tube installation is mandatory. Please read and understand the conditions and information included in this document. All pricing is based on a 15 mile radius of travel from the Salinas, CA office.

Often times wells are difficult to access: in the event access to a well is difficult or requires additional work; an additional charge will incurred at the current Service Call Rate plus any parts or materials used. This includes eroded,corroded,or rusty fittings that may be damaged during the normal course of the well test operations.

The term "Potable Water" carries a very specific meaning. If a "Potable Water Test" is required contact the office for more information and additional pricing.

Please Select the Payment Method:

C.O.D. or Check(at the time of inspection)

Credit Card (Call for processing)

Other

Auxiliary power supplies can be provided, in the event there is no current electrical utility service, or the service has been compromised, damaged, or is otherwise unusable. (Call the office for current estimates)

Note: We are no longer Billing open escrow accounts.

WELL REPORT PROPOSAL DEFINITIONS, ADDITIONAL TERMS, AND DISCLAIMERS:

Sole report. This report shall contain the sole observations and conclusions of DOUGHERTY PUMP & DRILLING INC. (hereinafter called the company) pertaining to the testing of the Customer's well. Any prior statements of the agents or employees of the company, which are not contained herein, are superseded by this report, and shall be relied upon at the Customer's own voluntary risk. The report shall contain but not be limited to all of the pages of this document together with the final report and shall be considered as one document and not severable.

Test limitations:. The data and conclusions to be provided shall be based upon the tests and measurements of the company using standard and accepted practices of the groundwater industry. However, conditions in water wells are subject to dramatic changes in even short periods of time. Additionally, the techniques employed may be subject to considerable error due to factors within the well and groundwater formations which are beyond the company's immediate control or observation. Therefore, the data are valid only as of the date and to the extent of the observational limitations of the test or installation indicated.

Use of test: The test conclusions are intended for general comparison of the well in its present condition against known water well standards or guidelines, and should not be relied upon to predict either the future quantity or quality of water that the well will produce. Wells should be periodically re-tested to show both seasonal and long-term fluctuations.

Disclaimers: In presenting the data and conclusions, the company makes no warranties, either express or implied, as to future water production of the well. Further, the company, unless expressly stated to the contrary, does not represent (1) that the well or pump system or any of its related equipment is in any particular condition or state of repair, or (2) that the test results will satisfy cognizant governmental ordinances or regulations, or (3) that the test duration or methodology is sufficient to meet local water system or new construction permit standards (which may require 24 hour or more tests), or (4) that the water is adequate for a particular purpose contemplated by Customer, or (5) the usefulness of the report for any purpose more than 30 days after the date of the test.

Unusual pumping conditions: Wells that break suction while pumping, or have high draw down in relation to the standing water level, are often indicative of marginal long-term water producers. These wells should have protective shutoff devices on the pumps to help prevent pump burnout from lack of water. A smaller capacity pump may improve electrical efficiency and sustain less wear by enabling longer pumping cycles. Conversely, in stronger wells, the pump itself may be too small to pump the full well capacity, and thus the true sustained (or average) yield may be higher than observed in this test.

Customer's release: In accepting this proposal and or authorizing the company to perform any type of (1) evaluation, (2) test, or (3) opinion, the Customer releases and holds the company harmless from liability for consequential or incidental damages arising, (4) out of the breach of an express, or implied warranty of future water production, or (5) in any manner through the further dissemination of this report, or its conclusions, by either Customer, or third parties, except as the dissemination is required to complete the project, or other activity for which the report was prepared, or (6) any and, or all physical damage to the well as a whole, the pump, or any of its related appendages, electrical wiring, or surrounding vegetation, soils, or structures.

During and after the test: While in the normal course of performing certain pump tests on a well, the well maybe operated, or pumped for a longer duration of time or a greater flow rate than during its normal day-to-day operation. The possibility of the well producing dirty water, sand, odors, or any other objectionable condition exists at the time of the test, and or may, at any time in the future after completion of the test. The afore mention potential conditions are beyond the direct, or indirect control of the of the company. Further, during the course of the test, pumping equipment may be subjected to conditions which could cause fatigue, wear, and or damage to the pumping equipment or the well, beyond that for which the company has no direct, or indirect control. The customer having read and acknowledged this document does hereby release and hold the company harmless from liability for consequential, or incidental damages arising from the afore mentioned (but not limited to) conditions.

Acceptance:

I have read and understand the definitions, additional terms, costs, and disclaimers in the afore mentioned document. By signing this document, I am agreeing to all of the conditions, definitions, additional terms, disclaimers, and costs set forth in this document.

Date:			Accepted By:
Date:			Accepted By:
Date:			Accepted By: