"Application for a Public Water System Well Site Suitability Certification" - Connecticut

Application for a Public Water System Well Site Suitability Certification is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on March 31, 2009;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download "Application for a Public Water System Well Site Suitability Certification" - Connecticut

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STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
DRINKING WATER SECTION
APPLICATION FOR A PUBLIC WATER SYSTEM WELL SITE SUITABILITY CERTIFICATION
PLEASE REFER TO INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR A PUBLIC WATER
SYSTEM WELL SITE SUITABILITY CERTIFICATION PRIOR TO FILLING OUT.
Application will be returned if it is incomplete
Section A. Public Water System and Applicant Information
PWS Name:
Project Name:
Project Address:
PWSID Number: CT
PWS Type (select one):
Community
NTNC
TNC
Town:
DPH Project Number (if known):
Print Name of PWS Administrative Official:
Title:
Address:
Phone Number:
Fax Number:
E-mail Address:
Name of Consultant
Company Name:
Address:
Phone Number:
Name of Licensed Well Driller (must be licensed in CT):
CT License Number:
Address:
Phone Number:
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STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
DRINKING WATER SECTION
APPLICATION FOR A PUBLIC WATER SYSTEM WELL SITE SUITABILITY CERTIFICATION
PLEASE REFER TO INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR A PUBLIC WATER
SYSTEM WELL SITE SUITABILITY CERTIFICATION PRIOR TO FILLING OUT.
Application will be returned if it is incomplete
Section A. Public Water System and Applicant Information
PWS Name:
Project Name:
Project Address:
PWSID Number: CT
PWS Type (select one):
Community
NTNC
TNC
Town:
DPH Project Number (if known):
Print Name of PWS Administrative Official:
Title:
Address:
Phone Number:
Fax Number:
E-mail Address:
Name of Consultant
Company Name:
Address:
Phone Number:
Name of Licensed Well Driller (must be licensed in CT):
CT License Number:
Address:
Phone Number:
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APPLICATION FOR A PUBLIC WATER SYSTEM WELL SITE SUITABILITY CERTIFICATION
Section B. Well Information
1. Purpose of proposed well (Check One):
New Public Water System Source
Replacement Well
Supplemental Well
2. Name of Proposed Well:
Type:
Bedrock
Gravel Packed
Other
3. Desired Withdrawal Rate (check one):
<10 gallons per minute (gpm)
10-50 gpm
>50 gpm
4. Indicate address where well will be located or closest town road or intersection:
5. Latitude and Longitude of proposed well site:
Lat:
°
” N Long:
°
” W
6. Is proposed well site staked or marked in the field?
Yes
No
Section C. Well Site Characteristics
1. Is the proposed well site located above the FEMA100-year flood elevation?
Yes
No (See RCSA Section 19-13-
B102(d)(1)(A) and instructions for completing.)
2. Does the public water system have full control (ownership) of the entire sanitary radius of the proposed well? If the public water
system does not have control of the sanitary radius, indicate below how control will be obtained.
3. Indicate the locations of all nearby existing public and private wells, their corresponding distances to the proposed well and
provide a brief description of potential effects the proposed new source of supply may have on these nearby systems.
Section D. Map Information
Attach a scaled site or street/zoning map certified by a Professional Engineer or Land Surveyor licensed in the State of Connecticut
containing the following items:
1.
Location of proposed well(s) with GPS points noted
2.
Adjacent public and private active/inactive well(s) that will be tested for interference during the yield test,
if applicable (CGS 25-33(b))
3.
Show the appropriate sanitary radius as listed in Section E Table 2.
4.
Sanitary Land conservation easement boundary, if applicable
5.
Existing and potential sources of pollution within 200 feet (see Section E Table 2)
6.
Topographic contours appropriate for the scale of the map.
7.
100-year flood elevation contour, if applicable
8.
North arrow
9.
Annual high water mark, wetland delineation, surface water bodies and watercourses (perennial and intermittent)
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APPLICATION FOR A PUBLIC WATER SYSTEM WELL SITE SUITABILITY CERTIFICATION
Section E. Sources of Pollution
1. Are there any known existing contaminated areas, as classified by the CT Department of Environmental Protection within a 1,500-
foot radius of the proposed well site?
Yes
No; If yes, then describe below the current condition of the area and indicate
separating distances from proposed well site.
2. Complete the following table:
Required separation distances (feet) based on well pumping rate
Actual
Pollution Source
Separation
< 10 gpm
10-50 gpm
> 50 gpm
Distance (feet)
Subsurface Sewage System
(septic tank/leaching fields)
75
150
200
Sanitary Sewer-Minimum separating
distances may be reduced under specific
conditions. Refer to the instructions for
75
150
200
details.
Storm Drain
25
50
50
Foundation, Floor Drain
25
50
50
Dry Well
75
150
200
High Water Mark for Surface Water Body
25
50
50
Liquid Fuel Storage Tank/Piping
75
150
200
Section F. Dioxin, Endothall, Beta Particle and Photon Emitter Assessment
The purpose of this section is to obtain an assessment to determine if the proposed site of a source of supply/well will be required to
be tested for Dioxin, Endothall and /or Beta Particle and Photon Emitters.
1. Complete and attach “Certification Form for Dioxin and Endothall”. Required only for Community and Non-Transient Non-
Community Water Systems; refer to the instructions for guidance.
2. Complete and Attach “Certification Form for Beta Particle and Photon Emitters”. Analyses required only for Community Water
Systems, refer to the instructions for guidance
Section G. Certification Statement
I certify to the best of my knowledge that the information provided in this application is complete and correct. I understand that the
information I provide will be used by the Department of Public Health, Drinking Water Section to determine if a Well Site Suitability
Certification can be granted. I further understand that if an approval is issued, the well must be drilled in the location approved by the
Department.
____________________________________________
________________________________
Signature of Applicant
Date
____________________________________________
________________________________
Name of Applicant (print or type)
Title (if applicable)
This application along with additional information on the public water system well approval process is located on the DPH Drinking
Water Section’s web page:
www.ct.gov/dph
click on “Programs and Services” then “Drinking Water”
Drinking Water Section Use Only
Date Stamped: _____________________________________
Assigned Staff Person: _______________________________
Project No: _____________________
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