APPENDIX J

Potential and Known Source Hazards, Controls, Assessment and Management
(Form IV-1)

From Form III-1; ('Source Identification Form') for this Site/Address:

City/Town _________________________________ Well Name ______________________________
EPA PWS Name and ID# ______________________ WHPA Zone # (1,2,3) ____________________ 

Form Completed By _________________________ Site Name/Address ______________________ 
Date ______________________________________
Name and describe the potential or known source and the source management strategy used to reduce or eliminate the risk of contamination from this source. Highlight each known, or existing source where a release has been identified, or if the site is listed on one of WDEQ's contaminated site databases. For sites/sources listed on one of WDEQ's databases, the management strategy will be "State Agency Oversight". For sites where a release has been identified but the site is not listed on one of WDEQ's databases, list the strategy as "?". Include the implementation date, or proposed implementation date for the management strategy. File one form for each site or address identified on the Source Inventory List.
     Example:

          Potential Source #:      #1
          Priority Rank #:         #5 (or Medium)
          Potential Source Type:   Abandoned Well
          Strategy:                Contact property owner to request that well be 
                                   properly plugged and abandoned.  Follow up with 
                                   contact or visit to confirm plugging.
          Implementation Date:     July, 1996.
Potential Source #___:  Priority Rank #____. Potential Source Type: ________________
Strategy:___________________________________________________________________________
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Implementation Date:________________________________________________________________ 
Potential Source #___:  Priority Rank #____. Potential Source Type: ________________
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Potential Source #___:  Priority Rank #____. Potential Source Type: ________________
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Implementation Date:________________________________________________________________ 
Potential Source #___:  Priority Rank #____. Potential Source Type: ________________
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Implementation Date:________________________________________________________________ 
Potential Source #___:  Priority Rank #____. Potential Source Type: ________________
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Implementation Date:________________________________________________________________ 
Potential Source #___:  Priority Rank #____. Potential Source Type: ________________
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Implementation Date:________________________________________________________________ 
Potential Source #___:  Priority Rank #____. Potential Source Type: ________________
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Implementation Date:________________________________________________________________ 
Potential Source #___:  Priority Rank #____. Potential Source Type: ________________
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Implementation Date:________________________________________________________________ 
Potential Source #___:  Priority Rank #____. Potential Source Type: ________________
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Implementation Date:________________________________________________________________ 

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Wellhead Protection Program Guidance Document Contents
Wyoming Department of Environmental Quality