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Tel: 800-249-1990 or 302-731-1700

Metsorb® - Arsenic Removal Evaluation Form
In order to allow us to provide an accurate estimate for arsenic removal, please complete the form with as much information as possible, and simply press the SUBMIT toggle when completed.

System Contact Information / Well Site Information

System Name: *

Site Location: *

System Type (Municipal, Utility, school, RV park, recreational, other): *

Contact Person / Operator: *

Phone Number: *

Fax:

E-mail: *

Address:

City: *

State: *

Zip: *

# of Connections:

Describe Existing Pretreatment:

Pump Operation and pressure:

Distribution Operation and pressure (in psi):

Electrical Power Available (Describe):

Sewer Outlet Available: Yes / No

Discharge Options (e.g., sanitary sewer, evaporation pond, etc.)

Desired System Startup Date:

Other considerations?

Please include the most recent laboratory reports and summarize the following. For a preliminary quote, items labeled *** must be included. A complete water quality review is necessary to accurately estimate cost and must be submitted for review prior to contract finalization.

Well Production Information

Current Usage
Well & Date
Max Pump or Design Flow Rate (GPM)***
Gallons per day***
Total Annual Production ***
(gallons per year)
Future Annual Production (gals per year)
Pump Discharge Pressure:

Water Analysis Summary

RAW WATER

COMMENTS

pH***
Total Arsenic ***
Arsenic V***
Arsenic III***
Silica***
Chromium (Total)**
Phosphate ***
Selenium†**
Uranium**
Vanadium**
Antimony
Boron
Calcium
Copper
Iron***
Lead
Manganese***
Mercury
Sulfate
Sulfides
Zinc
Average water temp
Alkalinity
Dissolved Solids***
Hardness (As CaCo3)***
Turbidity

© Graver Technologies, 2008.

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