Customer Material Questionnaire

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The Town of Woodworth Water System is required to update our lead and copper sample plan and complete an inventory of the service line materials in our distribution system by October 16, 2024. To assist with this endeavor, we are asking our customers to complete the brief survey below.

We understand that you may not be aware of your plumbing or service line materials and that is okay. However, we ask that you complete the questionnaire to the best of your ability and return it to us using the instructions provided at the end of the survey. We thank you for your cooperation in helping us comply with the Federal requirement. If you have any questions, you can reach us at: (318) 442-1198 or woodworth@thetow.org .

Customer Information:

Name *

Phone *

Do you own the property or are you renting? *

Owner
Renter

Property Information:

Address *

Address Line 1

City

State

Zip Code

Use a separate sheet for each property

Service Line Schematic:

As shown in the figure, a service line is the section of pipe that runs from the water main to the structure served. The system-owned portion of the service line runs from the water main to the meter. The customer-owned portion of the service line runs from the meter to the structure served. For the purposes of this inventory, we are only asking for the material of the customer-owned service line and the water piping materials inside of the home or building.

Material Questionnaire:

5. Do you have a water softener or a whole home water purification system or any other treatment device installed in your house or business?

6. If you answered yes to question 5, do you have an untreated, cold water kitchen or bathroom faucet?

7. If your home or business meets the criteria for lead and copper sampling, would you be willing to participate in this testing? During testing, a Water Supply Employee would bring an empty bottle to your house, provide you with documentation and instructions on collecting the sample, and pick it up the next morning. Sampling frequency is typically every three years and the sampling takes less than 5 minutes to complete.

I attest that, to the best of my knowledge, the information provided above is true and accurate:

Signature *

Clear Signature

Date *

Thank you for submitting your customer material questionnaire.

Town of Woodworth

Mayor’s Office | (318) 442-1284
Town Hall | (318) 442-1198
Fire Department | (318) 442-8861
Police Department | (318) 442-8980

9363 Hwy. US165 South
P.O. Box 228
Woodworth, LA 71485