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:
City:
County:
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
- Date well originally constructed (month/day/year): Last re-construction (month/day/year):
- Well driller:
- Type of well:
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Drilled |
Rotary |
Bored |
Cable Tool |
Dug |
Springs |
Ranney Collector |
Driven |
Jetted |
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Other:
Additional Comments:
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Yes (attach copy to form) |
No |
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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.
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Yes |
No |
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If so, what type of treatment is used?
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Disinfection |
Filtration |
Carbon Filter |
Air Stripper |
Other |
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Purpose of treatment (describe materials to be removed or controlled by treatment):
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Yes |
No |
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Residual chlorine level: (Point closest to source)
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topo. map |
altimeter |
drill/well log |
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Other:
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Yes |
No |
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How was water level determined? ____ Well log Other: _______________________________________________ ____ Measured
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Yes |
No |
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Is there evidence of a confining layer in the drilling log, well log, or geologic/engineering report?
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Yes |
No |
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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?
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Yes |
No |
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50 ft. |
100 ft. |
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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.
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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 |
Please indicated the occurrence of any test results since 1986 that meet the following conditions:
A. Nitrate as N:
(Nitrate MCL = 10 mg/L)
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Yes |
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Results greater than MCL |
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<2 mg/L nitrate |
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2-5 mg/L nitrate |
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>5 mg/L nitrate |
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No nitrate sampling records |
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B. VOCs:
(VOC detection level 0.5 μg/L)
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Yes |
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Results greater than MCL |
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VOCs detected at least once |
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VOCs never detected |
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No VOCs sampling records |
C. SOCs (Pesticides, etc.):
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Yes |
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Results greater than MCL |
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SOCs detected at least once |
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SOCs never detected |
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No SOCs sampling records |
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________________________________________________________________________________________
D. Bacteria contamination:|
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Yes |
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Any bacterial detection(s) in past 3 years in samples collected from the source (not distribution sampling records) |
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In past 3 years, has anyone found a bacteriological contamination problem in distribution samples that were attributed to the source? |
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No bacteria sampling records |
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| Yes | No |
If yes, please mark and identify on your WHPA map; describe:
| 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 |
| Yes | No |
| 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.
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
sources.
* Set an implementation date for each additional control.
Example:
Potential Contamination Source: Residential sources of pesticides and
fertilizers
Existing Controls: Manufacturers’ guidelines prescribe safe handling
and application of chemicals.
Adequately managed? No, highly vulnerable aquifer thought to require additional
controls.
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.
NOTES:
Emergency Contractors (list names and phone numbers):
Pump Servicing Contractor:
phone:
Well Drilling Contractor:
phone:
Heavy Equipment Operator:
phone:
Water Treatment Chemical Supplier (e.g., chlorine supplier):
phone:
Bottled Water Supplier:
phone:
County Emergency Coordinator:
phone:
Technical Consultants (e.g., geologist, engineer):
phone:
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:
1.
2.
3.
List the three most likely causes of future service interruptions, shortages,
or supply contamination:
1.
2.
3.
List anticipated response(s) to the above scenarios:
1.
2.
3.
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.):
1.
2.
3.
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.
Sections
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8
Appendices
A |
B |
C |
D |
E |
F |
G |
H |
I |
J |
K |
L |
M |
N |
O |
P |
Q |
R
Wellhead Protection Program Guidance Document Contents
Wyoming Department of Environmental Quality