Services

Personal Information

Full Name:*

Address:*

City:*

Postal Code:*

Directions:*

Home Telephone:*

Alternate Telephone:

Is the well accessible? The well must be accessible.*
Yes No

Useful Information

Number of Occupants:

What year was your well drilled (if known)?

What type of well do you have?
Dug/bored Drilled Unsure

Are you able to remove the well cap?
Yes No Unsure

What year was your septic system installed (if known)?

Is this waterfront property (this includes ponds and streams)?
Yes No

Do you have any neighbours that would be interested in a visit on the same day? Additional travel costs are waived if you both book visits on the same day.
Yes No

Have you recently switched to piped (municipal) water?
Yes No

Do you have a copy of your well record?
Yes No Unsure

Eligibility Notes

You must be the well/property owner; rental properties are eligible provided property owner is present during the guided self-assessment.

Scheduling Information

Please choose a preferred time for your Guided Self Assessment visit. Visits are conducted on Tuesdays and Thursdays. Visits generally begin at 9am and noon, and last approximately one and a half to two hours. We conduct visits in the Kingston, South Frontenac, Loyalist, Lennox and Addington, and Greater Napanee regions. After you submit this form, someone from Hearthmakers will contact you to book your appointment.

Preferred Day:
Tuesday Thursday

Preferred Time:

If you have any further scheduling restrictions (e.g., you are not available on Thursdays), please enter these below, and we will try our best to accommodate you:

Cost

The Guided Self Assessment of your well is FREE within 75 kms round-trip of downtown Kingston. Additional costs: $0.50 per additional km. The travel fee is waived if a neighbour also books a visit on the same day.

Miscellaneous Information

Visits are voluntary, confidential and non-regulatory. Well owners must sign an "Acknowledgment of Well Owner" waiver at the beginning of the visit, acknowledging that it is non-regulatory and educational in nature.

Guided Self Assessments are designed to help and educate you, the well owner. Your participation is required while the visit is taking place.

After the Guided Self Assessment has taken place, you will receive a written report for your information. This report is confidential, and is only provided to you.

Where did you hear about Well Aware Program?
In a newspaper article
On television
On the radio
On the Internet
In a government mailing
From a contractor
From a friend or colleague
From a display (If yes, where was the display? Please indicate below.)
From a neighbour
In a newspaper advertisement (If yes, in which newspaper? Please indicate below.)
Other (Please indicate below.)
Details:

If you have any questions or comments, please pass them on: