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2. First Name*

   Please include both spouse names (if applicable)

3. Last Name*
5. Phone Number (Evening)*
6. Email Address

   To be notified of any program changes

8. Mailing Address*
9. Well Address

   If different from mailing address

11. City (Mailing Address)*
12. State*
13. Zip Code*
15. Is the well located in the Town of Chilton?*
    -- Select One --YesNo

    If not, please use the other form located on the Calumet County Groundwater Testing Page

16. By registering, you understand that this is a self sample program. The sample must be drawn on and returned on Monday, August 17*
    -- Select One --Yes, I will collect samples on Monday, August 17 and return the same day
18. The Town of Chilton provides Homeowner's Package (Bacteria and Nitrate) for free. Do you wish to add on other tests at an additional cost?*

    1. Homeowner's Package- $0.00
    2. Add Metals Package - $75.00 (Includes 11 different metals including arsenic, recommended every 5-10 years)
    3. Add DACT Pesticide Screen - $45.00 (tests for atrazine and its byproducts, only recommended if you have high nitrate))
    4. Add Both Metals + DACT - $120.00

    HOMEOWNER'S PACKAGE: includes Bacteria, Nitrate, pH, Alkalinity, Hardness, Chloride, Conductivity, Corrosivity Index ... METALS PACKAGE: includes 11 metals, including an arsenic screen...... DACT SCREEN: tests for Atrazine and its byproducts

20. Kit Distribution (Pick Up Kits)*

    1. 5PM - 6:30PM Wednesday, August 12 at Chilton Town Hall
    2. 11AM - 1PM Wednesday, August 12 at Calumet County Courthouse Room 105A (next to Treasurer's office)
21. Payment (if applicable)*
    -- Select One --No Payment - I am only sampling the Homeowners Package (FREE)Check (Made out to Calumet County)

    Payment will be collected at time of kit distribution. Check only made out to Calumet County

22. Preferred Drop Off Time and Location*

    1. Monday, August 17, 11AM - 1PM Calumet County Courthouse, Room 105A (next to Treasurer's office)
    2. Monday, August 17, 5PM - 6:30PM, Chilton Town Hall
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24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

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