Final Version 8/23/11

Headwaters Resource Conservation & Development Council

Private Drinking Water Supply Testing near Marcellus Gas Well Drilling activities in the
following counties: Clearfield, Jefferson, Elk, Cameron, Clinton, Centre, Potter, & McKean
APPLICATION
Name: ______________________________________________________________________
Address: _____________________________________________________________________

_____________________________________________________________________
County of Residence: ____________________________________________________________
Phone: ______________________________________________________________________
Email: _______________________________________________________________________
Income Determination:
For the purposes of determining eligibility for the private water supply testing, the following information is necessary.
Each family should determine the number of persons living in the family and whether total family income exceeds or
falls below the listed figure for the appropriate family size. Before completing the survey, refer to the bottom of this
page for some examples to guide the income determination.
Please check the total income for:
1 PERSON
$ 31,750

Above ___
Below ___

5 PERSON
$ 48,950

Above ___
Below ___

2 PERSON
$ 36,250

Above ___
Below ___

6 PERSON
$ 52,550

Above ___
Below ___

3 PERSON
$ 40,800

Above ___
Below ___

7 PERSON
$ 56,200

Above ___
Below ___

4 PERSON
Above ___
8 + PERSON
Above ___
$ 45,300
Below ___
$ 59,800
Below ___
-----------------------------------------------------------------------------------------------------------ANNUAL INCOME INCLUDES:
1.
2.
3.
4.
5.
6.
7.

Gross wages before deductions of all adult members of the households.

The net income from operation of a business or profession or from rental of real or personal property.
Interest and dividends.
Social Security and pensions.
Unemployment Compensation, Disability Compensation, Workmens Compensation.
Public Assistance.
Alimony and child support.

ANNUAL INCOME DOES NOT INCLUDE:

1.
2.
3.

Income from dependent minors under age 18. Heads of households and spouses may never be considered minors.
Income of full-time students age 18 or older, who are not heads of households or spouses.
One-time additions to family assets such as inheritances, capital gains, settlement for personal or property losses.

*Please be sure to complete the water supply information on the back side of this page*

Water Supply Information: Please provide answers to as many of the following questions as you can.
Do you have a spring or a well _______________________________________________
Provide the latitude/longitude for the well/spring if you know it __________________________
Is this your primary source of water ___________________________________________
Do you have a secondary source of water ________________________________________
Is this a shared water supply ________________________________________________
If so, please provide their contact info if they would like to receive results as well ________________

__________________________________________________________________
What type of supply is it: residential, business, camp, or other ____________________________
Have you ever had your water tested before _______________________________________
Have you ever had any problems with your water such as
Taste_______
Odor _______
Color _______
Well/Spring run dry _______

Staining _______

Other______

If you have had previous problems, please describe as best you can _________________________

__________________________________________________________________
__________________________________________________________________
Do you have any form of treatment for your water _______________________________________________
If so, what type of treatment/what are you treating for (hard or soft water, iron etc) _______________

____________________________________________________________________________

___________________________________________________________________
*Should you be selected to receive a free water supply test and you have some form of water treatment,
someone will have to be present when water is sampled*
If you have a well please answer these additional questions:
Was your well drilled or hand dug? _____________________________________________

_____________________________________________________
When was it put in _______________________________________________________

How deep is you well

You will be notified as soon as possible if you are eligible for a free water test. If so, your results will be
presented to you at workshop later this year where you will learn how to interpret them. This workshop is
mandatory, and everyone receiving a water test through this program must send a representative.
Additionally, all individual water test data and information collected is confidential, however, by signing and
submitting this form you agree to allow Headwaters RC&D to use your results for future educational use.
Please complete this application, sign, and return it to:
Kelly Williams, Watershed Specialist
kwilliamsccd@atlanticbbn.net
Clearfield County Conservation District
814-765-2629
511 Spruce Street, Suite 6
Clearfield, PA 16830
Please note, completing and submitting this application does not guarantee that you will get a test done on your
water supply. If a number of requests come in for a single geographic area, we will complete as many tests as
necessary to get a representative sample of the groundwater in the area.