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Individual Water Supply wells: Application for the Installation of New and /or Replacement Potable Water Well

2. 

3. Wyoming County Health Department
   Environmental Division
   5362 Mungers Mill Road, Silver Springs, NY 14550
   Telephone 585-786-8894
   Individual Water Supply Wells<br>Appendix 5-B Application

   Individual Water Supply Wells
   Appendix 5-B Application

5. Application for the Installation of New and/or Replacement Potable Water Well

7. Name of Property Owner*

8. Email Address

10. Address*

12. City*

13. State*

14. Zip Code

16. Phone Number*

17. Cell Number

19. Nearest Crossroads:*

23. DEC Registered Well Driller?*

    1. Yes
    2. No

24. DEC Registration Number

26. Is a Waiver From Appendix 5-B Requested?*

    1. Yes
    2. No

27. If Yes Please Explain:

29. Well is located as to provide adequate access?*

    1. Yes
    2. No

30. Well is constructed as to not allow seasonal flooding?*

    1. Yes
    2. No

31. Well is located up gradient from potential sources of contamination?*

    1. Yes
    2. No

33. Achieved minimum separation distances as listed in Appendix 5-B, Table 1?*

    1. Yes
    2. No

34. Ground around the well is graded to divert surface water away from the well?*

    1. Yes
    2. No

36. GPS Well Latitude:

37. GPS Well Longitude

39. Type of Well Construction*

    1. Drilled
    2. Driven
    3. Excavated
    4. Other

40. If Other Please Describe

42. Well constructed according to requirements of Appendix 5-B, Table 2?*

    1. Yes
    2. No

43. Top of well casing is a minimum of 12" above finished grade?*

    1. Yes
    2. No

45. Depth of well casing is at least 19' below finished grade?*

    1. Yes
    2. No

46. if No, list any additional measures that have been taken to protect the supply

48. Top of casing has a watertight and vermin proof well cap?*

    1. Yes
    2. No

49. Is well casing properly vented?*

    1. Yes
    2. No

50. Is the well grouted?*

    1. Yes
    2. No

52. Connection to water well casing is made with a pitless adapter?*

    1. Yes
    2. No

53. If No, please explain

55. Type of Pump installed on the well?*

57. Does the well have any cross connections with another water supply?*

    1. Yes
    2. No

58. If Yes, please explain

60. Water well yield test was performed?*

    1. Yes
    2. No

61. Water level and flow rate observations were recorded?

    1. Yes
    2. No

62. Was the well properly disinfected prior to use?*

    1. Yes
    2. No

64. Was a bacteriological water sample collected from this source?*

    1. Yes
    2. No

65. If Yes, date the sample was collected?

66. Sample Results

    1. Acceptable
    2. Unacceptable

    (Please attach a copy of the report)

68. Please Note: A copy of the NYSDEC "Water Well Completion Report" Must be submitted with this application

70. Water Well Completion Report file upload

    If no file is uploaded please mail a copy of the report to complete submission of this application

Leave This Blank:


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit

* indicates a required field