Name:

Prudence Island Address:

City, State, Zip:

E-mail Address:

Are you experiencing any problems with your water?   Yes No

What sorts of problems are you having? (Check all that apply)

Low Pressure   Unpleasant Odor   Rust   Black Scum

Oily Scum   Particles (other than rust) White Foam or Froth

Other (Please explain your problem in the field below)

How often do you have these problems? Once a month or less More than once a month Once a week More than once a week Daily

If you are a full time resident, do you have problems more frequently on weekends than during the week?

Yes   No

Do you drink the tap water?   Yes   No

If you drink the tap water, do use use any type of filtering system?

Yes   No

If you use a filtering system, what type do you use?

None Filtering carafe Filter attached to tap Filtered before entering internal piping

If you don't drink tap water, how do you get drinking water?

Not applicable Buy at island stores Buy on the mainland Haul from Indian Spring

If you buy water to drink, can you estimate how much money you spend per month on drinking water?

$

Do you wash your laundry on the island? Yes   No

If you wash laundry on the island, have your clothes been damaged by rust or other contaminants?

Yes   No

Do you use Iron-Out or some other rust reduction product when washing your laundry?

Yes   No

Can you estimate the amount you spend per year rewashing and/or replacing damaged clothing?

$

If you bring your clothing to the mainland for laundering, can you estimate your cost per month?

$

Have your appliances or fixtures been stained or damaged in some other way by rust or other contaminants in the water?

Yes   No

If yes, which appliances and fixtures have been damaged? (Check all that apply)

Sinks   Toilets Tubs and Showers

Hot Water Heater Washer   Dishwasher

Other (please specify)

What kinds of things do you do to minimize the staining or other damage to your fixtures or appliances? (Check all that apply)

Frequent scrubbing with bleach or abrasives

Use CLR or some other rust removing chemical

Drain water heater regularly

Replace badly stained fixtures and/or appliances

Nothing, I've learned to live with it.

If you had to replace fixtures or appliances because of staining, have you done so within the past year?

Yes   No

Can you estimate your appliance/fixture replacement costs for the year?

$