C.M.R. 06, 096, ch. 405, app 096-405-B
WATER SUPPLY WELL DESCRIPTION FOR__________________
DATE: __________________________
1. Resident/Lessee/Property Owner
Name:________________________Name:_____________________________
Address:______________________Address:____________________________
______________________ ____________________________
______________________ ____________________________
Telephone:________________ Telephone:_________________________
2. Water used by (please check all that apply):
____ Private Home ____ Boarding Home
____ Several Families ____ Nursing Home
____ School ____ Bottling Plant
____ Church ____ Recreational Camp
____ Lodging Place ____ Manufacturing Facility
____ Eating Place ____ Agricultural Facility
____Other (please describe):_______________________________________
3. Number and approximate ages of persons living in residence, or otherwise served by this water source:
__________________________________________________________________
__________________________________________________________________
4. Public Water Supply Identification Number: ___________________________
5. Well Location:
Is the well located on this property? ____yes ____no
If no, please provide the following information regarding the well location:
Name or Lot Number:_____________________________________
Property Owner: _________________________________________
Address:_______________________________________________
_______________________________________________
_______________________________________________
Telephone:______________________________________________
WATER SUPPLY WELL DESCRIPTION FOR __________________________
6. Description of Well:
A. Date installed: ______________________________________
B. Who installed the well? Provide address if possible. _____ contractor_____ owner/occupant ____ other (describe)_________________________________
Name:____________________________________
Address:__________________________________ ____________________________________ ____________________________________
C. Type of well: ____dug____drilled____well point ____spring____lake/pond ____other (describe):_______________________________________
D. Depth of well: _______________________________________________
E. Depth to bedrock or ledge (or length of casing):____________________
F. Static water level:________________________
G. Yield (in gallons/minute): __________________
H. Lining: ____concrete____steel casing____clay tile ____other (describe):________________________________________
I. Piping: ____copper____galvanized____black plastic ____lead____PVC ____other (describe):______________________________________
J. Covering: ____boards____concrete____wellhouse ____other (describe):_______________________________________
K. Is the top of the well above ground? ____no____ yes
L. Is the water being treated?____no____yes If yes, how is it being treated: ____chlorinator____softener____pH control ____carbon____iron removal____sediment ____UV____iodinator ____other (describe):_______________________________________
WATER SUPPLY WELL DESCRIPTION FOR ___________________________
7. Water usage (check all that apply)
: ____drinking____cooking____bathing
____watering vegetable garden____swimming pool
____watering flower garden____watering livestock
____other (describe):________________________________________
8. Well distance from potential pollution sources:
A. cesspool ______ feet
B. septic tank ______ feet
C. leachfield ______feet
D. underground tank ______ feet
E. highway/road ______ feet
F. garden/cropland ______ feet
G. barnyard/pasture ______ feet
H. cemetery ______ feet
I. landfill ______ feet
J. lagoon ______ feet
K. waste pile ______ feet
L. manufacturing facility ______ feet
M. other ______ feet (describe:________________________________)
9. Type of sewage treatment:
____septic tank and leachfield____cesspool_____municipal
____other (describe): _____________________________________________
10. Is the soil:
____ sand and gravel_____ clay_____ till____ ledge
____ unknown____ other (describe): ____________________________
11. Does your water have any of the following?
Odor:____ yes____ no
Taste:____ yes____ no
Cloudy:____ yes____ no
Sediment:____ yes____ no
Color:____ yes____ no
Stains clothes or plumbing fixtures:____ yes____ no
12. If problems with water quality are indicated, please describe:______________________________
____________________________________
__________________________________
13. Was the water quality test requested by the resident? If yes, please state the reason for the request._________________________________
______________________________________________________
14. Additional comments:
_______________________________________________________________________
_______________________________________________________________________
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DO NOT WRITE BELOW THIS LINE (FOR DEPARTMENT USE ONLY)
Project Name:_________________________ Date of sample collection:____________
ANALYSIS REPORT
Date results received:_______________________
Satisfactory:______________________________
Unsatisfactory:____________________________
Further investigation warranted? ____ yes____ no
Recommended action: _______________________________________________________________________
_______________________________________________________________________
C.M.R. 06, 096, ch. 405, app 096-405-B