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2. Please fill out this survey only if you are located within city limits and you believe you have a well located on your property.
4. First Name*
5. Last Name*
7. Address*
9. Phone Number
10. Email
12. Is there a well on your property?

    1. Yes
    2. No
    3. Unsure

    • If "yes", please complete and submit this well survey and a site visit will be scheduled to obtain latitude/longitude coordinates of the well and to inspect for cross-connection.
    • If "no" or "unsure", please contact Chris Moody at 307-721-5213 or at wellregistration@cityoflaramie.org  
14. Has the well been used in the past 12 months?

    1. Yes
    2. No
    3. Unsure
16. If the well is currently inactive, when was it last used?
18. What is the well currently used for? For example, lawn/landscape watering, household purposes, basement water control
20. Is the well connected to the City municipal water system?

    1. Yes
    2. No
    3. Unsure
22. Do you have any concerns with the well? For example, physical condition or water quality?
24. Would you like the City to provide services and/or information to help you safely operate the well and address concerns with the well?

    1. Yes
    2. No
26. If you would like more information or would like to discuss, please contact us at wellregistration@cityoflaramie.org or leave a message at 307-721-5215
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field