{"id":11,"date":"2025-12-04T17:24:06","date_gmt":"2025-12-05T00:24:06","guid":{"rendered":"https:\/\/www.env.nm.gov\/morasanmigueltaos-pws\/mora-san-miguel-and-taos-county-private-well-sampling-form\/"},"modified":"2025-12-04T17:24:41","modified_gmt":"2025-12-05T00:24:41","slug":"mora-san-miguel-and-taos-county-private-well-sampling-form","status":"publish","type":"page","link":"https:\/\/www.env.nm.gov\/morasanmigueltaos-pws\/mora-san-miguel-and-taos-county-private-well-sampling-form\/","title":{"rendered":"Mora, San Miguel, and Taos County Private Well Sampling Form"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <p class='gform_description'>To sign up to have your private well tested, fill out our form below. Only residents of Mora, San Miguel, and Taos counties are eligible for testing.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/morasanmigueltaos-pws\/wp-json\/wp\/v2\/pages\/11' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_1_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Well Owner Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_22\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_22'>Today&#039;s Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_22' id='input_1_22' type='text' value='04\/16\/2026' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_22_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_22_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_22' class='gform_hidden' value='https:\/\/www.env.nm.gov\/morasanmigueltaos-pws\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_1_6' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_7\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_1_7' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_3\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Language Preferred<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_3'>\n\t\t\t<div class='gchoice gchoice_1_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='English'  id='choice_1_3_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_3_0' id='label_1_3_0' class='gform-field-label gform-field-label--type-inline'>English<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Spanish'  id='choice_1_3_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_3_1' id='label_1_3_1' class='gform-field-label gform-field-label--type-inline'>Spanish<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_3_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='gf_other_choice'  id='choice_1_3_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_3_2' id='label_1_3_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_1_3_other' class='gchoice_other_control' name='input_3_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_4\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Preferred Method of Contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_4'>\n\t\t\t<div class='gchoice gchoice_1_4_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Telephone'  id='choice_1_4_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_4_0' id='label_1_4_0' class='gform-field-label gform-field-label--type-inline'>Telephone<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_4_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Email'  id='choice_1_4_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_4_1' id='label_1_4_1' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_4_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='No preference'  id='choice_1_4_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_4_2' id='label_1_4_2' class='gform-field-label gform-field-label--type-inline'>No preference<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_5\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Physical Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_1_5_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_5_1' id='input_1_5_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_5_2_container' >\n                                        <input type='text' name='input_5.2' id='input_1_5_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_5_2' id='input_1_5_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_1_5_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_5_3' id='input_1_5_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_5_4_container' >\n                                        <select name='input_5.4' id='input_1_5_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' selected='selected'>New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_1_5_4' id='input_1_5_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_1_5_5' value=''    aria-required='true'    \/>\n                                    <label for='input_1_5_5' id='input_1_5_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_5.6' id='input_1_5_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_1_8\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-half field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Mailing Address<\/legend><div class='gfield_description' id='gfield_description_1_8'>If different from physical address<\/div>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_8' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_8_1_container' >\n                                        <input type='text' name='input_8.1' id='input_1_8_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_8_1' id='input_1_8_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_8_2_container' >\n                                        <input type='text' name='input_8.2' id='input_1_8_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_8_2' id='input_1_8_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_8_3_container' >\n                                    <input type='text' name='input_8.3' id='input_1_8_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_8_3' id='input_1_8_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_8_4_container' >\n                                        <select name='input_8.4' id='input_1_8_4'     aria-required='false'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' selected='selected'>New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_1_8_4' id='input_1_8_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_8_5_container' >\n                                    <input type='text' name='input_8.5' id='input_1_8_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_8_5' id='input_1_8_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_8.6' id='input_1_8_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_1_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Select County<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_1_9'>Select location of private well(s).<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_9'>\n\t\t\t<div class='gchoice gchoice_1_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Mora County'  id='choice_1_9_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_9\"   \/>\n\t\t\t\t\t<label for='choice_1_9_0' id='label_1_9_0' class='gform-field-label gform-field-label--type-inline'>Mora County<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='San Miguel County'  id='choice_1_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_9_1' id='label_1_9_1' class='gform-field-label gform-field-label--type-inline'>San Miguel County<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_9_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Taos County'  id='choice_1_9_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_9_2' id='label_1_9_2' class='gform-field-label gform-field-label--type-inline'>Taos County<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_10\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Number of Groundwater Wells on Property<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_10' id='input_1_10' type='text' step='any' min='1' max='500' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_10\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_10'>Please enter a number from <strong>1<\/strong> to <strong>500<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_1_11\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Well Usage<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_1_11'>Please check all that apply<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_11'><div class='gchoice gchoice_1_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Domestic'  id='choice_1_11_1'   aria-describedby=\"gfield_description_1_11\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_11_1' id='label_1_11_1' class='gform-field-label gform-field-label--type-inline'>Domestic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='Irrigation'  id='choice_1_11_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_11_2' id='label_1_11_2' class='gform-field-label gform-field-label--type-inline'>Irrigation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_11_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.3' type='checkbox'  value='Livestock'  id='choice_1_11_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_11_3' id='label_1_11_3' class='gform-field-label gform-field-label--type-inline'>Livestock<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_11_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.4' type='checkbox'  value='Other'  id='choice_1_11_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_11_4' id='label_1_11_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>If &quot;Other&quot; please describe usage<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_13\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Well Features<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_1_13'>Please check all that apply<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_13'><div class='gchoice gchoice_1_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Pump'  id='choice_1_13_1'   aria-describedby=\"gfield_description_1_13\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_1' id='label_1_13_1' class='gform-field-label gform-field-label--type-inline'>Pump<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='Electricity'  id='choice_1_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_2' id='label_1_13_2' class='gform-field-label gform-field-label--type-inline'>Electricity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='Pressure Tank'  id='choice_1_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_3' id='label_1_13_3' class='gform-field-label gform-field-label--type-inline'>Pressure Tank<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='Treatment System'  id='choice_1_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_4' id='label_1_13_4' class='gform-field-label gform-field-label--type-inline'>Treatment System<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.5' type='checkbox'  value='Water Softener'  id='choice_1_13_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_5' id='label_1_13_5' class='gform-field-label gform-field-label--type-inline'>Water Softener<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.6' type='checkbox'  value='Other'  id='choice_1_13_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_6' id='label_1_13_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>If &quot;Other&quot; please describe features<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does the well have a tap located outdoors before any treatment systems and\/or pressure or holding tank from which a water sample may be collected?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_15'>\n\t\t\t<div class='gchoice gchoice_1_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes'  id='choice_1_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_0' id='label_1_15_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_1_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_1' id='label_1_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='I don&#039;t know'  id='choice_1_15_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_2' id='label_1_15_2' class='gform-field-label gform-field-label--type-inline'>I don&#8217;t know<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>What is the well depth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_16'>Please answer &#8220;unknown&#8221; if you do not know.<\/div><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_16\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your well:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_23'>\n\t\t\t<div class='gchoice gchoice_1_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Currently operational with running water coming from a tap or spigot.'  id='choice_1_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_23_0' id='label_1_23_0' class='gform-field-label gform-field-label--type-inline'>Currently operational with running water coming from a tap or spigot.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Winterized until Spring.'  id='choice_1_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_23_1' id='label_1_23_1' class='gform-field-label gform-field-label--type-inline'>Winterized until Spring.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_23_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Damaged such that a tap or spigot is not operational.'  id='choice_1_23_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_23_2' id='label_1_23_2' class='gform-field-label gform-field-label--type-inline'>Damaged such that a tap or spigot is not operational.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_23_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Otherwise not operational.'  id='choice_1_23_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_23_3' id='label_1_23_3' class='gform-field-label gform-field-label--type-inline'>Otherwise not operational.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_17'>List any other information about the well or wells.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_17'>This includes (but is not limited to) information such as drill date, depth to groundwater, and New Mexico Office of the State Engineer ID Number (e.g., CR-12345)<\/div><div class='ginput_container ginput_container_text'><input name='input_17' id='input_1_17' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_17\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_18\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>Do you believe damage occurred to your private well or water supply during the 2022 Hermit&#039;s Peak-Calf Canyon Wildfire?<\/label><div class='gfield_description' id='gfield_description_1_18'>If so, please explain<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_18' id='input_1_18' class='textarea small'  aria-describedby=\"gfield_description_1_18\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Has your well been sampled previously?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_19'>\n\t\t\t<div class='gchoice gchoice_1_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' 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