Goochland/Powhatan Drinking Water Clinic September 2020

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Please fill in the blanks below and complete your registration by either mailing in a check for $60.00 or by stopping by the Goochland or Powhatan Extension Offices at:

Goochland Extension Office OR Powhatan Extension Office
2748 Dogtown Road 3910 Old Buckingham Road
Goochland, VA 23063 Powhatan, VA 23139

Note: Please refer to the Goochland or Powhatan flyer for specific information on the kickoff meeting in the respective counties. Samples kits are $60.00 each for those who want to test more than one well or multiple tests of the same well before and after a filtration system. Please make your check payable to the "Treasurer of Virginia Tech" *There is a $50 returned check fee*

First Name *

Last Name *

Phone *

E-mail

Street Address (Street, City, State, Zip) *

County (which you plan to pick up and drop off your sample kit) *

Goochland (Pick-up water sample bottle Kit on 9/21/20 - Drop-off filled water sample bottles on 9/23/20

Powhatan (Pick-up water sample bottle kit on 9/22/20 - Drop-off filled water sample bottles on 9/23/20

Number of Sample Kits Requested *

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