We’re trying something new to promote
water quality awareness in your area!

Fill out this brief survey,
give us your honest opinions and feedback
and get a $50.00 Gift Card* from
WalMart, Lowes or Home Depot

(No purchase necessary)

* = required field

My/Our $50.00 gift card choice is: *

 
 
 

Our water comes from: *

 
 

I/We currently use a water filtering/conditioning device at this address: *

 
 

We use the following filtering/conditioning devices: *

   
   
 

My/Our water sometimes has an odor or taste like: *

     
     
     

My/Our water sometimes stains fixtures: (toilet, tub, sink, etc.) *

 
 

The color of my/our tap water is: *

 
 
 
 

I/We drink bottled water: *

 
 

Number of persons age 18-64 in household: *

Number of persons age 65+ in household: *

Number of persons age 2-17 in household: *

Number of infants under 2 in household: *

I/We: *

 
 

If applicable, year home purchased:

If known, year home was built:

If we are in the area again, would you provide us with a water sample? *

 
 

Homeowner’s Name(s): *

Street Address: *

Zip Code: *

Phone Number: (for gift card, survey, feedback purposes only) *

Alternate Phone Number (optional for faster processing)

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The National Water Quality Awareness Coalition (NWQAC) is a national organization of water quality specialists who provide consumers with free information on municipal and P.O.U. water quality. NWQAC does not sell water treatment equipment and is not affiliated with any federal, state or municipal government agency. NWQAC is also not affiliated with the Environment Protection Agency (EPA) or any municipal water treatment facility. $50 gift card offer for homeowner’s participation. Some restrictions apply.