DIY Water Wise Indoor Survey Worksheet

Name

Address

City

Zip Code

Email

Telephone

Date of Survey

Meter reading

Provide the number shown on the dial or meter’s face.

Does your water meter register when all your water using fixtures and appliances are turned off?

Yes (Go to House Line Test)

No (Go to Toilet Test)

The House Line Test: Does the irrigation system branch off the house line before the house line shut-off valve?

Yes

No

Does the irrigation system have a shut-off valve?

Yes

No

After you turn off the house line and do a second Pin Test: Is there movement?

Yes (Call a plumber to fix a house line leak, or check irrigation system)

No (Leak is beyond this valve. Go to Toilet Test)

Turn on the house line valve using the same number of turns you to turn it off.

Did you find any leaks indoors?

Yes

No

Any signs of standing water damage?

Yes

No

Any signs of leakage or water damage?

Yes

No

If so, where?

Listen: Did you hear a noise?

Questions	Yes	No
Toilet 1	Yes	No
Toilet 2	Yes	No
Toilet 3	Yes	No

Look: Did your parts work smoothly?

Questions	Yes	No
Toilet 1	Yes	No
Toilet 2	Yes	No
Toilet 3	Yes	No

Look: Does water stop one inch below the top of the overflow pipe?

Questions	Yes	No
Toilet 1	Yes	No
Toilet 2	Yes	No
Toilet 3	Yes	No

Dye Test: Did the flapper leak?

Questions	Yes	No
Toilet 1	Yes	No
Toilet 2	Yes	No
Toilet 3	Yes	No

Showers: Do your showerheads use more than 2.0 gpm?

Yes

No

Total Showerheads

Shower Flow Rate A

Enter the highest flow rate

Shower Flow Rate B

Enter the next-highest flow rate

Do your bathroom sink faucets use more than 1 gallon per minute (gpm)?

Yes

No

If you found you have different flow rates throughout your home, enter the highest flow rates in ‘A’, then the next highest flow rate in ‘B’. If you have more than two flow rates,
please provide any additional details in the ‘Comments’ at the end of this form.

Total Bathroom Sink Faucets

Bathroom Sink Faucets Flow Rate A

Enter the highest flow rate

Bathroom Sink Faucets Flow Rate B

Enter the next-highest flow rate

Do your kitchen sink faucets use more than 1.5 gallon per minute (gpm)?

Yes

No

Total Kitchen Sink Faucets

Kitchen Sink Faucets Flow Rate A

Enter the highest flow rate

Kitchen Sink Faucets Flow Rate B

Enter the next-highest flow rate

Notes:

Please note we will send you efficient faucet aerators, showerheads or toilet flappers based on your responses above, which may be less than what you specify below.

Toilet Flappers Requested

Showerheads Requested

For a 2.0 gpm showerheads, enter the quantity you want. Otherwise, check your local hardware store for even more efficient WaterSense-labeled showerheads.

Bathroom Sink Aerators Requested

Kitchen Sink Aerators Requested

Is there any sign of water damage around your appliances?

Yes

No

Comments

Disclaimer: Please do not upload personal or sensitive materials through this form. We may ask for additional materials while processing your request.

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