Master Well Owner Application

Click here to download the paper application

Applicant Information:

First Name:

Last Name:

Date of Birth:

Street Address:

City:

State:

Zip:

Phone Number:

Email Address:

County:

Gender: Male Female

Occupation:

Program Interest

Do you own or work at a business associated with private water systems (i.e. well drilling, water treatment, etc.)? Yes No

 

If yes, please describe the business:

Do you own a private water well, spring or cistern and depend on it for the water supply to your primary home, vacation home, or camp? Yes No

 

Briefly explain why you are interested in becoming a Master Well Owner:

Are you willing and able to attend a 1 day training workshop? Yes No

 

Are you willing to work to fulfill the requirements of educating 100 people about private water well management over the course of 2 years? Agreeing to work towards this goal is a requirement of the program. Yes No

 

Are you willing to have your name listed on our website if you become a certified Master Well Owner? Yes No

 

Have you had any formal or informal education about water? If yes, please describe. Yes No

 

If yes, please describe the extend of your education:

By clicking submit I acknowledge that I have read and understand the Virginia Master Well Owner volunteer expectations and policy.

Thank you for your interest. You will be notified within two weeks if you have been selected to participate. If you have any questions feel free to contact the coordinator.

If you rely on a well, spring or cistern for your water supply, you are responsible for the safety of your family's water! This means you should take steps toward maintaining and protecting your well and regularly test your water.