Irrigation System Maintenance Agreement


Service Address:

Service City:

New Customers: Please provide service address
if different from billing.

Billing Information:
* Required


*First Name:


*Last Name:


*Billing Address:






*Zip Code:


*Mobile Number (for appt. reminders):


*Email (for appt. reminders):


Mobile Number:




(skip this section if it does not apply to you) 

First Name:


Last Name:


  By checking this box, I authorize the above caretaker to schedule service appointments for my irrigation system. I understand that I will be billed directly for all repairs and services.


Agreement and Authorization

By submitting this form, I authorize Gilford Well Company, Inc. to perform the following services (select the services you want each year):


Service Description

Preferred Time of Year

Standard Rate


  • Blow out lines with air compressor
  • Remove pump/backflow (store at location or GWC)
  • Note any repairs to be made in spring

Early Fall
Mid Fall
Late Fall

(pay when invoiced)

Please remove me from the list, I no longer require these services



Credit Card (Optional Pre-Payment):



Credit Card Number:


Expiration Date:


Amount to Charge:



what is this?The Credit Card Verification Value is the 3 digit code on the back of your card.


I Authorize Gilford Well Company to charge
the above credit card for the amount given:


We are committed to protecting your privacy at Gilford Well Company We will not collect any personal information from you that you do not volunteer, and we are the sole owner of all information collected on this site. We do not sell, share, or rent this information to others in any way that we have not mentioned in this statement.