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2. Water quality is a priority for the City of Bluffton. To help us better understand how our water system is performing, we ask customers who are experiencing water qualities issues to please complete this form.

4. Contact Information

6. First Name*
7. Last Name*
9. Service Address Where Issue is Occurring*
11. City*
12. State*
13. Zip Code*
15. Contact Phone Number*
16. Contact Email Address*

20. Water Quality Issue Observations

22. Date Issue First Discovered*
    Date Issue First Discovered
24. Please indicate specific issue(s) occurring at the listed service address (check all that apply):
26. Scaling / Crusting:

    1. Plumbing Fixtures
    2. Water Filter
    3. Dehumidifier
    4. Other (Explain in Provided Field)
28. Other Scaling / Crusting Observed:
30. Taste Issues:

    1. Chlorine
    2. Salty
    3. Sulfur
31. Odor Issues

    1. Chlorine
    2. Sulfur
33. Other Water Quality Issue(s) Observed:

    1. Chalky White Residue
    2. Oily Film
    3. Cloudy Appearance
    4. Other (Explain in Provided Field)
35. Other Water Quality Issue(s) Observed:
37. Is the issue occurring throughout the entire home and/or business?

    1. Yes
    2. No
39. If No, Where Specifically is the Issue Occurring? (i.e. kitchen, bathroom, etc.)

43. Additional Information

45. Do you own a water softener?

    1. Yes
    2. No
47. Additional Comments Pertaining to this Issue:
49. Information Consent*

    1. I consent to the City of Bluffton, Indiana storing my submitted information so they can respond to my inquiry.
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field