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06-096DEPARTMENT OF ENVIRONMENTAL PROTECTION

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):_______________________________________

Chapter 405: Water Quality Monitoring, Leachate Monitoring, and Waste Characterization

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