City/Town ____________________________________ Well Name ___________________________ EPA PWS ID# __________________________________ WHPA Zone # (1,2,3) _________________ Form Completed By ____________________________ Date ________________________________ Type of Survey _____________________________________________________________________ (i.e., windshield survey, personal interview, site inspection, etc.) Name of Person(s) Interviewed ______________________________________________________
Site Name ________________________ Owner/Leaseholder _______________________________ Phone # __________________________ Site Location/Address ___________________________ Owner's/ Leaseholder's Address _____________________________________________________
Residential ___ Retail ___ Agricultural ___ Industrial ___ Government ___ Other ___
POTENTIAL SOURCE | CODE | QUANTITY | COMMENTS |
1) (Example) Animal Feedlot | 0006 | 1 | Approximately 150 Head of Cattle |
2) | _________ | ___________ | _______________________________ |
3) | _________ | ___________ | _______________________________ |
4) | _________ | ___________ | _______________________________ |
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12) | _________ | ___________ | _______________________________ |
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Appendices
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Q |
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Wellhead Protection Program Guidance Document Contents
Wyoming Department of Environmental Quality