This form has been developed in order to help assess the susceptibility of your groundwater source(s) to potential sources of contamination. The Wyoming Department of Environmental Quality, Water Quality Division (WDEQ/WQD) will use the information on this form to evaluate geologic and hydrologic factors associated with each of your Public Water System (PWS) sources (i.e. well, spring or tunnel) in order to estimate the source's potential vulnerability to contaminants that are regulated under the Safe Drinking Water Act (SDWA).
IMPORTANT! When submitted by a 'Non-community' Public Water System (See Glossary) 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.
Regardless of the type of Public Water System (Community, Transient Non-community, or Non-transient Non-community) the Susceptibility Assessment Form (Appendix F) must be completed and included as part of any Wellhead Protection Plan submitted to WDEQ for approval.
The information requested on this form may be gathered from a variety of records. Some information can be found on your Statement of Completion and Description of Well or Spring (Form UW 6) filed with the State Engineer's Office (SEO). Please take the time to verify this information. If this information is not current, please note any needed changes. Other useful records include your source and system monitoring records as well as system design plans, water right records, engineering and geologic reports, and water quality monitoring records. If your records are not complete, you may be able to obtain some of this information from the SEO, WDEQ/WQD, or the Wyoming Water Development Commission.
Many of the questions request information about the construction of your well. If your water system utilizes only springs or tunnels, you should still complete the Susceptibility Assessment Form; simply leave blank those questions which do not apply.
Incorrect information or incomplete forms may raise your susceptibility risk evaluation. For these reasons it is important that you take some time to complete the form to the best of your ability. You may not have all of the information that is requested on the form. You may indicate "information unavailable/unknown" in response to certain queries if this is the case.
EPA and Vulnerability:
In 1986 Congress passed amendments to the Safe Drinking Water Act (SDWA). These amendments have been implemented in phases. The most recent phases to be implemented are Phase II and Phase V monitoring requirements which went into effect between 1993 and 1995. Phase II and V deal mainly with monitoring for volatile organic and synthetic organic compounds (VOCs and SOCs). Under Phase II & V the monitoring requirements for these compounds are significantly increased for Public Water Systems (PWS). Realizing that the increased monitoring requirements can be very costly to water systems, EPA has allowed PWSs to reduce or waive monitoring requirements depending upon how vulnerable the water system's sources are to contamination. That is, those sources which are vulnerable to contamination may have more monitoring requirements while those sources that are less vulnerable may have reduced or no monitoring required for many chemicals.
What is Vulnerability?
Vulnerability can be thought of as a water source's (e.g. well, spring or tunnel) potential for contamination. Vulnerability is composed of two factors: the physical susceptibility to the infiltration of contaminants; and the source's risk of exposure to contaminants. Susceptibility is determined by conditions that affect the movement of contaminants from the land surface into a water supply. This would include the depth of the well, its construction, the geology of the area, the pumping rate, the source(s) of groundwater recharge, and the aquifer material. The risk of exposure to contaminants is determined by whether or not contaminants were used in the area of a water supply.
In order to determine a drinking water source's vulnerability to contamination WDEQ/WQD has developed the Susceptibility Assessment Survey Form. This survey form catalogs key susceptibility factors for each source in order to evaluate overall susceptibility. The following information is needed to evaluate hydrologic susceptibility:
Depending on the results of the susceptibility assessment, EPA may allow that some or all of the monitoring requirements (number and type of paramters, frequency of monitoring) for certain chemicals be waived. This type of waiver is considered to be a "susceptibility waiver". If source information does not allow a system to qualify for a susceptibility waiver, the system can pursue other types of waivers. One option, the Contaminant Use Waiver, involves a more intense inventory of the contaminants that may be found within the source's recharge area. "State-wide waivers" may also offer some monitoring relief. These are blanket waivers granted for chemicals not commonly detected in the state.
PART I: System Information
With a few exceptions, all of the information in this section can be taken from your State Engineer's Office (SEO) Statement of Completion (Form UW 6). The SEO should have a copy on file if your copy has been misplaced. Of particular concern is the information concerning source location and quarter/quarter section, and well depth. You should also note the population served and number of connections in this section; this information should be available from the water system records. Please use this opportunity to review your system records and make sure they are up-to-date.
There are optional items in this section. These include the State Engineer's Office permit number and a latitude and longitude location. If this information is not readily available, these areas can be left blank.
PART II: Well Construction and Aquifer Characteristics Information
Most of the well information can be obtained from the Statement of Completion (Form UW 6 filed with the State Engineer's Office) and design plans that were prepared for the water system. In some cases the information may be found in other system records. Estimates can be made for some factors but these responses must be identified as estimates.
1) Date Well Constructed/Reconstructed:
2) Well Driller:
3) Well Type:
4) Well Report (Well Log):
5) Average Pumping Rate:
6) Source Treatment:
It is possible that your system has more than one source that is combined prior to treatment. If that is the case, please record this information in the comment section.
7) Chlorine Residuals:
8) Depth to Top of Open Interval:
9) Depth to Groundwater:
This information may be listed in pounds per square inch (psi) or as a flow rate in gallons per minute (gpm). If the information is listed as a flow rate be sure it is not a pumping rate.
11) Surface Impoundments and Reservoirs:
12) Wellhead Elevation:
13) Confining Layers:
14) 'Accident Prevention Zone' (Zone 1 of the WHPA):
15) Wellhead Control and Access:
16) Surface (or Inner) Casing and Annular Seal:
17) Surface (Protective) Casing, Seal and Well Cap:
PART III: Assessment of Water Quality
1) Regional Sources of Risk to Groundwater:
'Community' PWSs: Mark and identify the potential sources on the WHPA map, together with other potential sources in your Contaminant Source Inventory' (see Section III, Wyoming's Wellhead Protection Guidance Document).
"Pesticide application" refers to those areas, excluding residential areas, where pesticides, hebicides, insecticides, etc. are commonly applied. Examples include agricultural land, managed forest land, nurseries, and recreational areas (golf courses, parks), all with areas greater than about 2 acres. Also consider right-of-ways (state/county highways, railroads, electric/telephone lines) where herbicides are applied and mosquito/vermin control areas. State and County Public Works Departments, County Weed and Pest Control Offices, and County Agricultural Extension Offices can often supply much of this information.
"Other injection wells" can include French drains (stone-lined pits or trenches) into which liquid waste is poured and allowed to percolate into the ground.
Local governments and health departments may also be able to provide information concerning known contaminant sources such as landfills, clean-up sites, permitted waste discharge sites and businesses or industries that store or dispose of significant quantities of hazardous waste materials in the immediate vicinity of your water supplies (service stations, auto shops, dry cleaners, chemical manufacturing/processing, etc.). This information may also be obtained by contacting WDEQ-Division of Solid and Hazardous Waste. Telephone numbers of municipal and county agencies can be found in the government listings in the White Pages of your telephone directory; state agency contacts are provided in Table III-2 of Wyoming's Wellhead Protection Guidance Document.
If you are unable to obtain sufficient information from public agencies to respond to this question, a simple alternative is to identify the area on a local map and complete either a walking or driving survey of the area, noting potential sources of contamination as discussed in Section III of Wyoming's Wellhead Protection Guidance Document.
2) Source Specific Water Quality Records:
B) Volatile Organic Compounds (VOCs) - MCLs vary for each VOC. Use EPA or lab notification of MCL violations. Total Trihalomethane (TTHM) data should not be considered here.
C) Synthetic Organic Compounds (SOCs) - If you have completed any pesticide monitoring the results should be recorded in this section.
D) Bacterial Contamination - Use coliform monitoring records to respond. IMPORTANT: The main emphasis in this set of questions is to identify those water sources that have a history of source related bacterial contamination. Most of the current bacterial testing is done within a system's distribution system and not at the source. Bacterial contamination in the water system does not necessarily indicate contamination of the groundwater source.
PART IV: Geographic or Hydrologic Factors Contributing to a Non-Circular Zone of Contribution
The following questions will help identify aquifer conditions which may not be accurately represented by the Calculated Fixed Radius (CFR) method; answer these questions only if you are a 'Non-Community' PWS, or a 'Community' PWS using the Calculated Fixed Radius (CFR) method to delineate the WHPA. If you answer Yes' to questions #1, 2(B), 3 or 4 you must either modify the WHPA accordingly or apply one or more alternative delineation methods (see Appendix D, Wyoming's Wellhead Protection Guidance Document) in order to obtain WDEQ approval.
1) Hydrologic Boundaries:
Topo maps can be purchased locally throughout the state at map stores, camping stores, etc. You may need more than one map to include your WHPA. If you use a U.S. Geological Survey topographic map please use one that is based on a 7 1/2 minute scale.
2) Aquifer Material:
B) Do any of the above mentioned sources of information reveal or indicate that the well is located in an area where the underground conditions are fractured, faulted or karst?
3) Groundwater Flow Type and High Horizontal Flow Rate:
4) High-Volume Wells:
PART V: Potential Source Hazards, Controls, Assessment and Management
The ultimate objective of Wellhead Protection is to prevent groundwater contamination within the Wellhead Protection Area (WHPA). Therefore, management of potential contaminant sources (within the WHPA) is an essential component of Wellhead Protection. Non-community PWSs that submit this form (as their WHP plan) to WDEQ/WQD must describe the techniques that will be employed to manage and minimize the threats posed by the potential contamination sources identified
1) Management of Existing and Future Contaminant Sources:
Regulatory Management Strategies:
Non-Regulatory Management Strategies:
Regulatory management strategies generally can afford a greater degree of protection, as compared to non-regulatory methods. A more complete description of the applicability, including examples of these strategies is provided in Section IV and Appendices I and L of Wyoming's Wellhead Protection Guidance Document.
PART VI: Contingency Planning (Non-Community PWSs Only)
The purpose of this section is to address problems that Non-community Public Water Systems need to overcome in the event of water supply shortages or contamination incidents that may impact the system's ability to supply an adequate quantity of safe drinking water to the public. Contingency plans should focus on the identification of, and solutions for, problems that may arise if protective and preventative measures fail. Potential emergencies such as well, wellfield, or spring contamination, water shortages due to droughts, and interruption of water supply due to power outages or infrastructure failure should be identified and addressed in a contingency plan.
1) Contingency Plan Organization:
In formulating a contingency plan, the Non-Community PWS must address the following considerations: (1) existing system condition and the possible water system failure modes; (2) responsibilities during an emergency; (3) emergency response procedures and contacts; (4) development of new ground and surface water sources in case of long-term shortages or abandonment of contaminated supplies; and (5) sources of emergency funds and procedures for requesting and dispersing such funds. Chapter V of Wyoming's Wellhead Protection Guidance Document (Planning for the Future) can be referenced for more specific contingency planning, additional guidance and information.
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Wellhead Protection Program Guidance Document Contents
Wyoming Department of Environmental Quality