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This is a Indiana form that can be used for Water within Statewide, Department Of Enviromental Management.
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NEW WELL SITE SURVEY State Form 50896 (R4 / 3-06) Date Submitted: Indiana Department of Environmental Management Office of Water Quality INSTRUCTIONS: Complete all information and mail two (2) copies to: IDEM, OWQ, DWB, Field Inspection Section 100 N. Senate Avenue, MC: 66-34 Indianapolis, IN 46204-2251 SECTION I - FOR ALL PUBLIC WATER SUPPLY SYSTEMS 1. System Name (Facility): 3. Mailing Address: 4. City of Facility: 6. System Contact Person: 8. Type of Application: New System Well Replacement Well Additional Well 9. Provide the location of the proposed well site in UTM or Lat/Long coordinates. (Please provide this information on a separate sheet of paper in your packet.) SECTION II - FOR COMMUNITY PUBLIC WATER SUPPLY SYSTEMS By 327 IAC 8-4.1 and 327 IAC 8-3.4 all community systems must submit: Location in Packet IDEM Use Only Information Present? Reviewer Item # 2. System PWSID number: 5. County of Facility: 7. Telephone number: ( ) - 1. A USGS topographical map showing the areas surrounding the well and proposed well site. 2. A map drawn to a scale between 1"=400' and 1"=1,000', showing: A. Ownership and any easement boundaries of the proposed well site, B. The location of the proposed well, C. The isolation area, D. The wellhead protection area. 3. A summary of the aquifer system used by the proposed well where available. 4. An inventory of potential sources of contamination within a 3000' radius of the proposed well. 5. A schedule for the development of a Phase I Wellhead Protection Plan. 6. Driving directions to the proposed well site. SECTION III FOR NONCOMMUNITY PUBLIC WATER SUPPLY SYSTEMS By 327 IAC 8-3.4 all noncommunity systems must submit: 1. A map drawn to a scale showing: A. Ownership and any easement boundaries of the proposed well site, B. The location of the proposed well, C. The isolation area, D. An inventory of potential sources of contamination within a 1000' radius of the proposed well. 2. The name of the USGS topographical map(s) for the proposed well site. 3. A summary of the aquifer system used by the proposed well where available. 4. Driving directions to the proposed well site. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 American LegalNet, Inc. www.FormsWorkflow.com General Instructions - The application provides a check-list to ensure that all required information is provided. A well site visit will not be scheduled until all of the required information is submitted. In the column "Location in Packet" indicate the page number in the packet where each item may be found. Mail two (2) copies of the requested information to: IDEM, OWQ, DWB, Field Inspection Section, 100 N. Senate Avenue, MC: 66-34, Indianapolis, IN 46204-2251. Instructions for Section I - For All Public Water Supply Systems 1. System name as it should appear on all reports and correspondence. If the system is currently in operation this is the name currently being used. 2. Public Water Supply Identification Number (PWSID #), a unique number assigned to every public water system. If you have not been assigned a number, leave this blank and one will be assigned at a later date. If you are currently an operating system you have a PWSID and should provide it here. 3.-5. The mailing address to be used for correspondence with the system along with the city and county. 6.-7. Contact person and telephone number. This will be the person that IDEM will contact concerning the public water system. 8. Indicate the type of application; a new well for a new public water system; a replacement well is replacing a well at an existing public water system; and an additional well is adding a well to an existing public water system. 9. On a separate sheet of paper (not on this application) provide the UTM or Latitude and Longitude coordinates for the proposed well site. Instructions for Section II - For Community Public Water Supply Systems (a system with year round residents) 1. The topographical map showing the proposed well site and the area around the well. If you do not use the entire map make sure the map name, number, and scale are included in the "cut-up" version. Topographical maps are available for a small fee from the Department of Natural Resources, Map Sales Division. You may contact the Map Sales Division at (317) 232-4180. 2. A detailed map drawn to a scale between 1" = 1000' and 1" = 400'. (1" = 1000' is 2x the scale of a topographical map). The map must show the following: a. Easements and property ownership boundaries for the property where the proposed well site will be located. b. Locate as precisely as possible on the map where the proposed well will be located. c. For community systems this is a 200' radius from the proposed well location. d. Indicate the Wellhead Protection Area. The wellhead rule (327 IAC 8-4.1) provides five methods to delineate a wellhead protection area. For a proposed well ANY of these methods can be used regardless of the proposed pumping or actual pumping of the system. This means that ANY system can use a 3000' fixed radius for the proposed well site application. This does not qualify the system to use the 3000' fixed radius as a delineation method for your Wellhead Protection Plan nor does this application qualify as a Wellhead Protection Plan. For more information about delineation methods refer to 327 IAC 8-4.1or call the wellhead protection program at (317) 308-3308. 3. If there has been a study or report for the aquifer system a summary of the report must be included. 4. A potential sources of contamination inventory performed in the 3,000' radius of the well which lists existing facilities, sites, practices, and activities for both regulated and unregulated potential sources of contamination. The inventory must be submitted in the following form: a. A map with the potential sources of contamination plotted showing their locations relative to the wellhead protection boundaries drawn to a scale between 1" = 400' and 1" = 1000'. b. A table containing information describing the potential sources of contamination including: (i) Facility I.D. Number (cross-referenced to `b' above); (ii) Facility name and location; (iii) Site description; (iv) Any environmental permits issued for the site, including number and agency issuing the permit; (v) Types of contaminants at the site; and, (vi) The operating status of site. c. A narrative description of land uses within the Wellhead Protection Area. 5. Provide a schedule for the development of the required Phase I portion of