Form Center

2. 
3. 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
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