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

  1. County Seal (color)

  2. Wyoming County Health Department
    Environmental Division
    5362 Mungers Mill Road, Silver Springs, NY 14550
    Telephone 585-786-8894

    Individual Water Supply Wells
    Appendix 5-B Application

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

  4. DEC Registered Well Driller?*

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

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

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

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

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

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

  11. Type of Well Construction*

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

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

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

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

  16. Is well casing properly vented?*

  17. Is the well grouted?*

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

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

  20. Water well yield test was performed?*

  21. Water level and flow rate observations were recorded?

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

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

  24. Sample Results

    (Please attach a copy of the report)

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

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

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  28. This field is not part of the form submission.