Protecting and Monitoring Water Resources - Oil and Gas Development in USA

Private Well Water System Owner Outreach and Assistance Program - Oil and Gas Development for USA

This online survey is the portal that B.F. Environmental Consultants and the Water Research Center is using to provide free assistance to private well owners and water supply owners that are seeking technical assistance related to oil and natural gas development in the United States. In addition, we can provide free technical assistance in helping to solve common water quality problems. We are using this portal to facilitate communications and provide you the information or assistance you need. This portal is designed and maintained by Mr. Brian Oram, B.F. Environmental Consultants and the Water Research Center.

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* 1. The purpose of this project is to help us meet and provide outreach to private well owners in the United States. This is a project being conducted by B.F. Environmental Consultants Inc and the Water Research Center. You are invited to participate in this project because you are a private well owner. Your participation in this project is voluntary. You may choose not to participate. If you decide to participate in this survey, please accept the terms and conditions. If you decide not to participate in this study or if you withdrawl from participating at any time, you will not be penalized.

The procedure involves filling an online survey that will take approximately 5 minutes. Your individual responses will be confidential, but we will use a summary of all this information in our outreach efforts, education materials, or targetted assistance.

If you have any questions about the research study, please contact Mr. Brian Oram at bfenviro@ptd.net

ELECTRONIC CONSENT: Please select your choice below.
Clicking on the "agree" button below indicates that:

• you have read the above information
• you voluntarily agree to participate
• you are at least 18 years of age

If you do not wish to participate in the research study, please decline participation by clicking on the "disagree" button.

Agree

Disagree

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* 2. Please provide general contact information. This question requires an answer to only select questions (name, city, state, zip, and county) -you will not be contacted unless you ask.

Name: *

Company:

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

County *

Email Address: *

Phone Number:

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* 3. What type of assistance do you need?

Assistance with a Private Water System - well, spring, cistern

Assistance with a Public Water System, i.e., City Water

Assistance with a Rain Capture System

Other (please specify)

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* 4. What is the problem or concern? (Use the other section to add more detail)

Poor Water Quality

Not sure if Water is Safe to Drink ?

Health Concern

Had Water Testing Done, but do not know what to do next?

Need Certified Baseline Testing

Had Certified Baseline Testing - But do not understand the results?

Other (please specify)

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* 5. What type of activities are occuring around your well or water source?

Natural Gas Drilling (Vertical Wells)

Natural Gas Drilling with Hydraulic Fracturing (Horizontal Drilling)

Pipeline Construction

Oil Drilling

Brine Water Treatment and Recycling

Brine Water Injection - Deep Well Injection

Storage Pits

Gasoline Station

Landfills

Agricultural Activity

Known Hazardous Waste Site

Industrical Activity

Machine Shop

Other (please specify)

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* 6. Please provide any other information?

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* 7. If this is a community concern, would you be interested in helping to host a community meeting?

Yes

Maybe

Yes, but someone else or an organization is the contact - Please provide the necessary contact information in other.

Other (please specify)

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* 8. Thanks for Participating in this Survey Portal - You can find a lot of free information on general water quality at http://www.water-research.net. If you would like to receive a free refirgerator magnet and/or our booklet, please answer YES.

Yes

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* 9. Would you like to add any additional information? You will be contacted shortly - Thanks Mr. Brian Oram - If you are not contacted in a timely manner - email me bfenviro@ptd.net - I will help you personally. If you would like to learn more about our program, visit - http://www.carbonwaters.org and http://www.pacleanwater.org.