Code of Maine Rules
06 - DEPARTMENT OF ENVIRONMENTAL PROTECTION
096 - DEPARTMENT OF ENVIRONMENTAL PROTECTION - GENERAL
Chapter 405 - Solid Waste Management Rules: Water Quality Monitoring, Leachate Monitoring, and Waste Characterization
Appendix 096-405-B - WATER SUPPLY WELL DESCRIPTION

Current through 2024-38, September 18, 2024

WATER SUPPLY WELL DESCRIPTION FOR__________________

DATE: __________________________

1. Resident/Lessee/Property Owner

Name:________________________Name:_____________________________

Address:______________________Address:____________________________

______________________ ____________________________

______________________ ____________________________

Telephone:________________ Telephone:_________________________

2. Water used by (please check all that apply):

____ Private Home ____ Boarding Home

____ Several Families ____ Nursing Home

____ School ____ Bottling Plant

____ Church ____ Recreational Camp

____ Lodging Place ____ Manufacturing Facility

____ Eating Place ____ Agricultural Facility

____Other (please describe):_______________________________________

3. Number and approximate ages of persons living in residence, or otherwise served by this water source:

__________________________________________________________________

__________________________________________________________________

4. Public Water Supply Identification Number: ___________________________

5. Well Location:

Is the well located on this property? ____yes ____no

If no, please provide the following information regarding the well location:

Name or Lot Number:_____________________________________

Property Owner: _________________________________________

Address:_______________________________________________

_______________________________________________

_______________________________________________

Telephone:______________________________________________

WATER SUPPLY WELL DESCRIPTION FOR __________________________

6. Description of Well:

A. Date installed: ______________________________________

B. Who installed the well? Provide address if possible. _____ contractor_____ owner/occupant ____ other (describe)_________________________________

Name:____________________________________

Address:__________________________________ ____________________________________ ____________________________________

C. Type of well: ____dug____drilled____well point ____spring____lake/pond ____other (describe):_______________________________________

D. Depth of well: _______________________________________________

E. Depth to bedrock or ledge (or length of casing):____________________

F. Static water level:________________________

G. Yield (in gallons/minute): __________________

H. Lining: ____concrete____steel casing____clay tile ____other (describe):________________________________________

I. Piping: ____copper____galvanized____black plastic ____lead____PVC ____other (describe):______________________________________

J. Covering: ____boards____concrete____wellhouse ____other (describe):_______________________________________

K. Is the top of the well above ground? ____no____ yes

L. Is the water being treated?____no____yes If yes, how is it being treated: ____chlorinator____softener____pH control ____carbon____iron removal____sediment ____UV____iodinator ____other (describe):_______________________________________

WATER SUPPLY WELL DESCRIPTION FOR ___________________________

7. Water usage (check all that apply)

: ____drinking____cooking____bathing

____watering vegetable garden____swimming pool

____watering flower garden____watering livestock

____other (describe):________________________________________

8. Well distance from potential pollution sources:

A. cesspool ______ feet

B. septic tank ______ feet

C. leachfield ______feet

D. underground tank ______ feet

E. highway/road ______ feet

F. garden/cropland ______ feet

G. barnyard/pasture ______ feet

H. cemetery ______ feet

I. landfill ______ feet

J. lagoon ______ feet

K. waste pile ______ feet

L. manufacturing facility ______ feet

M. other ______ feet (describe:________________________________)

9. Type of sewage treatment:

____septic tank and leachfield____cesspool_____municipal

____other (describe): _____________________________________________

10. Is the soil:

____ sand and gravel_____ clay_____ till____ ledge

____ unknown____ other (describe): ____________________________

11. Does your water have any of the following?

Odor:____ yes____ no

Taste:____ yes____ no

Cloudy:____ yes____ no

Sediment:____ yes____ no

Color:____ yes____ no

Stains clothes or plumbing fixtures:____ yes____ no

12. If problems with water quality are indicated, please describe:______________________________

____________________________________

__________________________________

13. Was the water quality test requested by the resident? If yes, please state the reason for the request._________________________________

______________________________________________________

14. Additional comments:

_______________________________________________________________________

_______________________________________________________________________

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DO NOT WRITE BELOW THIS LINE (FOR DEPARTMENT USE ONLY)

Project Name:_________________________ Date of sample collection:____________

ANALYSIS REPORT

Date results received:_______________________

Satisfactory:______________________________

Unsatisfactory:____________________________

Further investigation warranted? ____ yes____ no

Recommended action: _______________________________________________________________________

_______________________________________________________________________