Water and Utility Questionnaires Water Well Testing Name* First Last Email PhoneAddress Street Address Address Line 2 City STATEAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have a private water well at your residence?*If you answer No, please provide your digital signature at the bottom of the form. Yes No Will you allow RH energytrans to test your water prior to and after pipeline construction? Yes No If yes, what is the best time to contact you to arrange for testing?MorningAfternoonEveningWhat is the approximate distance of your well from a residence (in feet)?Is your water well less than 200ft from the Risberg Line Right of Way? Yes No Approximate distance if less than 200ft from Right of WayWell Information, if Available:When was the water well drilled? What is the well depth?Does your well have a casing? Yes No What is the type of casing? Digital Signature* Please sign this form electronically by checking this box, indicating that the person signing is the same as the name listed above CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ Underground Utilities Name* First Last Do you have any underground utility lines such as cable TV, propane, water, electrical, sewer, drainage, etc. located on your property that you feel could be impacted by pipeline construction activities?*If you answer No, please provide your digital signature at the bottom of the form. Yes No Please list the type(s) of underground utilities:If possible, please provide an image or drawing of your property that details the locations of any utility lines relative to your house.Accepted file types: jpg, gif, png, tiff, pdf, Max. file size: 64 MB.If you are unable to upload an image file, please describe your property as best you can.Digital Signature* Please sign this form electronically by checking this box, indicating that the person signing is the same as the name listed above CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ
