Private Well Initiative - Water Sampling Results Tool Place Holder | Department of Health

Sanitarian Services Private Water Well Testing Form

Step 1: Info Form

Step 2: Confirmation

Step 3: Payment

Applicant Information

*Denotes a required field.

*First Name

*Last Name

*Address

Address 2

*City

*State

*Zip

*Email

*Phone

*Parish

Is the location of the well/property being tested the same as the mailing address?

How would you like to receive your testing results?
Email Standard Mail Both

Well/Property Location

*Denotes a required field.

*Physical Address

Physical Address 2

*City

*State

*Zip

*Parish