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| What is your water source? |
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| Is your well located within 1 mile of any of the following? |
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| Is your home located within 250 feet of any of the following? |
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| Has your home been treated for termites? |
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| What type of plumbing do you have? |
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| Is the age of your well greater than 30 years? |
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| Does your water exhibit any of the following? |
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| Do you use or have any of the following around your home? |
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