Environmental

Homeowner Questionnaire

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PFOS/PFOA Drinking Water Sampling 
Homeowner Questionnaire

If the drinking water consumed on your property comes from local groundwater (e.g., a private well, a community well), the Navy would like to sample drinking water to test for perfluorooctane sulfonate (PFOS) and perfluorooctanoic acid (PFOA).

If you do not have a drinking water well, please complete the questionnaire by marking “NO” and return to the Navy. If your property uses local groundwater for drinking and cooking, please complete as much of the questionnaire as possible and return to the Navy. Completed forms can be returned to the Navy by:

  • Printing it out and mailing to: MCOLF Drinking Water Investigation, 5701 Cleveland Street Suite 200, Virginia Beach, VA, 23462 (Questionnaire to Print), or
  • Submitting it online using the form below, or
  • Emailing it to NavyAtlanticWater@usmc.mil, or 
  • leaving a voicemail at 1-877-MCOLF17 (626-5317) including your name, property address, and telephone number

 

 
 
*
*
 
 
 
*
 
*
 YES
 NO
 
 YES
 NO
If YES, please let us know where that community well is located and provide contact information for the drinking water system operator:
 
 RENT
 OWN
 
 YES
 NO
If YES how many homes? How many apartments?
 
 YES
 NO
 
 YES
 NO
(e.g. when it was installed, well depth, well location, and screen length)
If YES, please provide details (e.g. when it was installed, well depth, well location, screen length, etc...)
 
 YES
 NO
(e.g. storage tanks, water treatment)
If YES, please specify (e.g. storage tanks, water treatment, etc...)
 
 YES
 NO
(e.g. additional well for irrigation or livestock)
 
 YES
 NO

 

Form Submittal

  • Please submit this form by entering the 5 character code and press submit.
*
 
 
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