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Cooling Tower Diagnostic Survey

Please complete one form per tower. Click on Submit when ready to send.

Warning: Since this form is large, it takes a while to transmit, once you press SUBMIT, so please be patient. An acknowledgement page WILL show up.

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Company Name:

Client's E-mail address:



 Telephone Number:  

 Contact: (Name & title)
 AM Distributor  

Send instructions/reports to:


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System Description
 Manufacturer's Name of Tower Chiller , etc
 Type of Tower/Chiller:
 Mfr's. Name: Compresser and Refrigerant System:


  • Hrs/day
  • Days/wk
  • Continuous
  • Intermittent
 Rated Tonnage of Tower
 Water Recirculation RateGPM

 Dimensions of Pan:

  • Width
  • Length
  • Water Depth
 Materials of Construction:

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Flow Diagram

 You may submit a diagram by FAX at 540-636-1770 or give us a word flow chart below

Example: raw waste pump station --> pond 1 (aerated, lined) --> ponds 2, 3 ,4, & 5 (settling and unlined) --> sludge holding pond


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Site Conditions/Water Source


  • Forced
  • Induced
  • Natural

 Source of Makeup Water

  • City
  • Well
  • Softened
 Amount of makeup used per 24 hours
 Makeup line pressure - psi

 How is Makeup Controlled?

  • Float
  • Manual
 Is there Provision for Bleed? Yes No
 If yes above, Rate and Location :
 Is a Feeder Present? Yes No
 If yes, Type of Feeder: If yes, Location of Feeder:

 Results of Analysis:

  • TDS
  • Conductivity(mmho)
  • TH
  • CaH
  • MgH
  • Turbidity
  • M
  • P
  • pH
  • Cl
  • SO4
  • SiO2
  • Langelier Index
  • Alkalinity as CaCo3


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Current Treatment Program:
 System  Manufacturer  Formula  Lbs/day  Cost/lb  Feeding Point

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Current Chemical Control Testing
Control Tests Frequency of Plant Tests  Limits of Plant Tests   Open Recirculation Tests Closed Recirculation Tests   Once Through Tests


 Corrosion Monitoring Program:

 Condition of Equipment:



Closed System


Chemical Feed System

 How will Alken-Murray treatment be fed into the system?
 What is Cooling Water Used For?
 Present Condition of System (Scale, Slime, Mud, etc.)
 Temperature of influent water (water to tower)F.
 Temperature of effluent water (water leaving the tower)F.
 How Frequently is the System Cleaned - (Method)?

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Effluent Disposal
 Is an NPDES Permit in Effect? Yes No
 Receiving body
 Pre or Post Treatment
 Restrictions/Permit Effluent Limits:
 Dilution Water Available:

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Miscellaneous Notes

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We usually add all people who inquire about our products to our newsletter mailing list, which is kept for in-house use. We do not ever sell or trade names of our clients, and rarely contact by e-mail more than once a month.

Mailing list: YES NO

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click here for original format survey form to print and faxfor original format to print, fill-in with a pen and fax