Amendment_0004_Attachment_3_Sherman_Creek_North_Well_Site_Eval_Report_2pgs_0004.pdf

Water System Information Water System Name: County:

Contact Person: Phone #:

Address: City: State: Zip:

Location of Well on Property:

Source #: Section: Township: Range:

Well Tax Parcel #: Unique Well ID#:

GPS Coordinates (if available): System Type: ☐ A-Comm ☐ A-TNC (Check One) ☐ A-NTNC ☐ Group B

Well means the spot where the well will be or is already drilled. Well site means the entire area within the 100-foot radius of the well or beyond 100-feet if it is determined there will be a significant impact on the well.

Yes No N/A

1. Map provided was accurate, based upon your observation at well site? ☐ ☐ ☐

2. Slope of ground within well site is such that contamination due to run-off and flooding potential is at a minimum? ☐ ☐ ☐

3. Site is safe from natural and manmade disasters? (Proximity to Flood Zone?) ☐ ☐ ☐

4. Public or private roads are avoided as far as possible? ☐ ☐ ☐

5. If private roads pass within 100' of the well, are they ditched or drained to safely conduct surface run-off away from well and outside the 100-foot SCA? (No public roads allowed in the 100' SCA). ☐ ☐ ☐

6. Contamination sources, such as septic tanks, chemicals, underground storage tanks, surface water, and dry wells are absent from well site? ☐ ☐ ☐

7. Is the annular seal present and at least 18-feet? ☐ ☐ ☐

8. Does the casing terminate at least 12-inches above grade? ☐ ☐ ☐

9. If an air vent is present, is it screened? ☐ ☐ ☐

10. If the well is in a pit, is the pit drained to daylight? ☐ ☐ ☐

11. Is general housekeeping satisfactory? ☐ ☐ ☐

12. Is the wellhead accessible for maintenance? ☐ ☐ ☐

13. Is there a source meter installed? ☐ ☐ ☐

14. Is there a raw water sample tap installed? ☐ ☐ ☐

15. Is the well site legally protected against contamination? (title, covenants) ☐ ☐ ☐

16. Is this source a spring? (If “Yes”, refer applicant to DOH) ☐ ☐ ☐

17. Is this source a dug well? (If “Yes”, refer applicant to DOH) ☐ ☐ ☐

18. Is the first open interval of the well less than 50-feet deep and the well is within 200-feet of a stream, pond, lake, river, irrigation ditch, or other body of water? (If “Yes”, refer applicant to DOH) Note: If the well has not yet been drilled and the site is located near a body of water, advise applicant to drill, case, and seal greater than 50-feet. ☐ ☐ ☐

Northeast Tri County Health District Well Site Evaluation Inspection Form

This well site is considered: ☐ Satisfactory ☐ Satisfactory with Correctable Deficiencies ☐ Not Satisfactory ☐ Requesting DOH to Review Site

Is this a replacement well? ☐ Yes ☐ No

If yes, reason for replacement:

Person(s) met on site for inspection:

Comments:

Inspector’s Name: __________________________ Date: _____________ Signature: _____________________________

AliceDay Underline

AliceDay Underline

AliceDay Underline

The proposed well location shown on the attached map is approximate. The following mitigation measures will be required when siting and drilling the well and preparing the design for the water system improvements:

1. Private roads are likely to pass within 100' of the well. If a private road passes through the 100' Sanitary Control Area (SCA), the road must be ditched or drained to safely conduct surface run-off away from well and outside the 100-foot SCA.

2. A protective covenant must be established for the SCA. If the SCA extends beyond the property lines, the well site must be legally protected through title notices and protective covenants.

3. The well will likely be located within 200' of surface water. If the well is located within 200' of the OHWM, the well must be drilled, cased, and sealed to a depth greater than 50'.