Note: this form sends e-mail to SURVEY@DAMAGEVALUATI ON.COM;


We are interested in your opinion about water use and potential groundwater contamination. We need your answers to these questions to help make decisions about future groundwater programs.

Q-1. Have you read or heard anything about groundwater being contaminated somewhere in your state or somewhere in your own county, city, or community?

No Yes -- In My State Yes -- In my county, city, or community Don't Know

Q-2. Have you read or heard anything about groundwater contamination in your county, city, or community coming from any of these specific sources?

1. No - Haven't Heard 2.  Yes -- But Can't Recall Specific Source 3.  Yes -- Superfund or Other Toxic or Hazardous Waste Site 4.  Yes -- A Public Landfill
5. Yes -- Agricultural Application of Pesticides or Fertilizers 6.  Yes -- Septic Tanks 7.  Yes -- Leaky Underground Storage Tanks or Lagoons 8.  Yes -- A Chemical Spill

9. Yes -- Other (please specify)

Q-3. How much do you agree or disagree with the following statement "We should protect groundwater at all costs."

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