Susceptibility Assessment Form
(Version 1.0)

IMPORTANT! When submitted by a ‘Non-community’ Public Water System and approved by WDEQ, this form and its accompanying map illustrating the delineated Wellhead Protection Area (WHPA), may serve as that PWS’s Wellhead Protection Plan. This form (and accompanying map) may not serve as a complete Wellhead Protection Plan for a ‘Community’ Public Water System; ‘Community’ systems must meet the requirements (i.e WHPA Delineation Report, etc.) identified in Wyoming’s Wellhead Protection Guidance Document, including completion of this form, in order to obtain WDEQ approval of their Wellhead Protection Plan.

Please complete one form for each groundwater source (well, spring, or tunnel) used in your Public Water System (PWS). Photocopy this form as necessary. Refer to Appendix G (Assistance Package) for details and instructions for completing this form.

Part I: System Information

Well owner/manager:                                                         
PWS Name:                                                                   
PWS ID # (EPA):                                                             
Well depth (feet):                                                          
Source (e.g. well) name:                                                    
State Engineer's Office Permit No.:                                         
Number of connections:         Population Served:                           
Township:   Range:   Section:   ¼, ¼ Section:                               
Latitude/longitude (if available):                                          
   How was lat./long. determined?
     global positioning device     survey     topo. map   other:            
Part II: Well Construction and Aquifer Characteristics Information
  1. Date well originally constructed (month/day/year): Last re-construction (month/day/year):
  2. Well driller:
  3. Type of well:




Cable Tool



Ranney Collector












Additional Comments:                                                   

  • State Engineer’s Office (SEO) Statement of Completion report available?
  • Yes
    (attach copy to form)



    If no well log is available, please attach any other records documenting well 
    construction, such as boring logs, "as-built" diagrams, engineering 
    reports, or well reconstruction logs.
  • Average pumping rate: gallons per minute (gpm). SEO adjudicated (permitted) pumping rate: gallons per minute (gpm). Source of information: If not documented, how was pumping rate determined?
  • Is this source treated?
  • Yes




    If so, what type of treatment is used?



    Carbon Filter

    Air Stripper







    Purpose of treatment (describe materials to be removed or controlled by treatment): 
  • Is source chlorinated?
  • Yes




    Residual chlorine level:      (Point closest to source)

  • Wellhead Elevation (feet above mean sea level): How was wellhead elevation determined?
  • topo. map


    drill/well log




  • Depth to top of screened interval: Feet below wellhead.
  • Depth to groundwater (static water level): Feet below wellhead. Flowing well/spring?
  • Yes




    How was water level determined?
    ____ Well log   Other: _______________________________________________
    ____ Measured
  • If the source is a flowing well or spring, what is the shut-in pressure? psi (pounds per square inch), or feet above wellhead
  • If source is a flowing well or spring, is there a surface impoundment, reservoir, or catchment associated with this source?
  • Yes




  • Confining layers: (This question can be completed only for those sources with a drilling log, well log, or geologic/engineering report describing subsurface conditions).

    Is there evidence of a confining layer in the drilling log, well log, or geologic/engineering report?

  • Yes




    If there is evidence of a confining layer, is the depth to groundwater more than 
    20 feet above the bottom of the lowest confining layers?





  • ‘Accident Prevention Zone’ (Zone 1 of WHPA):
  • 50 ft.

    100 ft.



    The criteria that determine an acceptable radius (i.e 50' or 100') of the 
    ‘Accident Prevention Zone’ (Zone 1 of WHPA) are established in 
    Section II, Wyoming’s Wellhead Protection Guidance Document.
  • Wellhead control and access: No wellhead control Wellhead enclosed in a wellhouse: Wellhead enclosed in a pitless adapter: Controlled access (please describe): Other uses for wellhouse (please describe):
  • Surface casing and annular seal: Surface casing present? Depth of surface casing: Surface casing material: Annular seal present? Depth of annular seal: Annular seal material:
  • Surface seal and well opening: Surface (protective) casing present? Height of surface casing above ground: Surface casing material and diameter: Well cap in place? Well cap locked? Surface seal present? Surface seal material: Length: Width: Thickness: Condition of seal: Seal slope away from casing?
  • Part III: Assessment of Water Quality

    1. Indicate if any of the following potential contaminant sources listed on the Table are present within Zones 1, 2 or 3 of your Wellhead Protection Area (WHPA).

      Type of Potential Source

      Zone 1

      Zone 2

      Zone 3

      Pesticide application      
      Stormwater injection wells

      Other injection wells

      Abandoned water wells

      Abandoned oil wells

      Landfills, dumps, disposal areas

      Known hazardous materials clean-up site

      Known water quality problems

      Population density >1 house/acre

      Septic systems, Cesspools, Outhouses, Privies

      Wastewater or sewage treatment lagoons

      Sites used for land application of sewage sludge or other wastes

      If other recorded or potential sources of groundwater contamination (See Table III-1, Wyoming’s Wellhead Protection Guidance Document) exist within the WHPA, please describe below (use additional sheets if necessary):
    2. Source-specific water quality records:

      Please indicated the occurrence of any test results since 1986 that meet the following conditions:

      A. Nitrate as N:
      (Nitrate MCL = 10 mg/L)



      Results greater than MCL

      <2 mg/L nitrate


      2-5 mg/L nitrate


      >5 mg/L nitrate


      No nitrate sampling records


      B. VOCs:
      (VOC detection level 0.5 μg/L)



      Results greater than MCL

      VOCs detected at least once


      VOCs never detected


      No VOCs sampling records

      C. SOCs (Pesticides, etc.):



      Results greater than MCL

      SOCs detected at least once


      SOCs never detected


      No SOCs sampling records


      If any SOCs were detected, please identify and date. Laboratory data sheets may be submitted in lieu of compiling list. If SOCs tests were performed, but no SOCs detected, list test methods here:___________________________________________________________________________________


      D. Bacteria contamination:



      Any bacterial detection(s) in past 3 years in samples collected from the source (not distribution sampling records)


      In past 3 years, has anyone found a bacteriological contamination problem in distribution samples that were attributed to the source?


      No bacteria sampling records


    Part IV: Geographic or Hydrologic Factors Contributing to a Non-Circular Zone of Contribution

    1. Is there evidence of a potential hydrologic boundary within the WHPA? (i.e. Does the boundary extend over a stream, river, lake, up a steep slope, or over a mountain or ridge?)

      Yes No

      If yes, please mark and identify on your WHPA map; describe:

    2. Aquifer Material: A. Have drilling logs, well logs, geologic maps, aerial photos, geologic/engineering reports and/or aquifer/pump test data been reviewed and analyzed for the presence of faulting, fracturing and karst conditions, both within the aquifer as well as within any overlying strata or sediments?

      Yes No

      Indicate which of the above have been reviewed; cite references used:

      B. Do any of the information sources in (A) above indicate that the well is located in an area where the underground conditions are fractured, faulted or karst?

      Yes No

    3. Do any of the information sources in 2(A) above indicate that the well is located in an area where the underground conditions are primarily identified as coarse sand and gravel?

      Yes No

    4. Are there other high-capacity wells (municipal, agricultural, and/or industrial) located within the WHPA?

      Yes No

      A. Presence of groundwater extraction wells pumping more than approximately 500 gallons per minute within ...

      Yes No Unknown
      Zone 1      
      Zone 2

      Zone 3

      B. Presence of groundwater recharge wells (e.g. drainage wells, etc.) or heavy irrigation within...

      Yes No Unknown
      Zone 1      
      Zone 2

      Zone 3

      Please identify or describe additional hydrologic or geographic conditions 
      that you believe may affect the shape of the WHPA for this source. Where 
      possible, reference them to their location on the map.

      Part V: Potential Source Hazards, Controls, Assessment, and Management

      Only ‘Non-Community’ Public Water Systems need to complete this part.
      Name and describe the management strategy (or strategies) you are planning to 
      implement to help reduce the potential for contamination of the drinking water 
      supply by the potential contamination source(s) located within the Wellhead 
      Protection Area (WHPA). Also, please include the date you will begin implementation 
      of each strategy. Complete this form for each potential contamination source.
      * Plan additional controls for inadequately controlled potential contamination 
      * Set an implementation date for each additional control.
      Potential Contamination Source: Residential sources of pesticides and 
      Existing Controls: Manufacturers’ guidelines prescribe safe handling 
        and application of chemicals.
      Adequately managed? No, highly vulnerable aquifer thought to require additional 
      Strategy 1: Acme Lawn Care -  Description: Establish an agreement for them 
        to install spill protection in their bulk mixing area.
      Implementation Date: 3/15/95
      Strategy 2: Public education -  Description: Issue an educational brochure 
        to homeowners about the proper use of pesticides and fertilizers within 
        source protection areas.
      Implementation Date: 4/21/95
      Potential Contamination source:                                             
      Existing Controls:                                                          
      Adequately Managed?                                                         
      Strategy 1:                       Description:                              
                                             Implementation Date:                 
      Strategy 2:                       Description:                              
                                             Implementation Date:                 
      * Keep Records
      File Copies of all public education programs, letters, memoranda of agreement, 
      memoranda of understanding, permits, etc., for this potential contamination 
      source behind this cover sheet.

      Part VI: Contingency Planning

      Emergency Contractors (list names and phone numbers):
      Pump Servicing Contractor:                                                  
      Well Drilling Contractor:                                                   
      Heavy Equipment Operator:                                                   
      Water Treatment Chemical Supplier (e.g., chlorine supplier):                
      Bottled Water Supplier:                                                     
      County Emergency Coordinator:                                               
      Technical Consultants (e.g., geologist, engineer):                          
      List causes of last three water supply service interruptions, shortages or 
      contamination events and briefly explain how each situation was resolved and 
      steps take to prevent the recurrence of each:
      List the three most likely causes of future service interruptions, shortages, 
      or supply contamination:
      List anticipated response(s) to the above scenarios:
      List steps that could be taken to lessen the possibility of the above scenarios
      occurring (e.g., provide back-up emergency power supply, installation of a backup 
      well, etc.):
      List possible alternative water sources that could be used in the case of a 
      service interruption or contamination event.  (If the alternative is a nearby 
      well, indicate whether it develops water from the same aquifer as main water 
      supply well, if known.):                                                    
      List emergency funding source(s) that may be utilized to prevent interruption 
      of the water supply or to restore the water supply.                         

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      Wellhead Protection Program Guidance Document Contents
      Wyoming Department of Environmental Quality