Water1

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?

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."

Strongly Disagree						Strongly Agree
1	2	3	4	5	6	7

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