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06-096DEPARTMENT OF ENVIRONMENTAL PROTECTION

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

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

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