DEQ Form CWHP "Checklist for Wellhead Protection" - Oklahoma

What Is DEQ Form CWHP?

This is a legal form that was released by the Oklahoma Department of Environmental Quality - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2013;
  • The latest edition provided by the Oklahoma Department of Environmental Quality;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DEQ Form CWHP by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Environmental Quality.

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Download DEQ Form CWHP "Checklist for Wellhead Protection" - Oklahoma

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Oklahoma Department of Environmental Quality
Water Quality Division | Phone: 405-702-8100
Construction Permitting Section
707 N. Robinson, OKC, OK 73102-6010
P.O. Box 1677, OKC, OK 73101-1677
Checklist for Wellhead Protection
APPLICANT'S NAME: ________________________________________________________________________
ADDRESS: _________________________________________________________________________________
CITY: ____________________________________________________ ZIP CODE: _______________________
COUNTY: __________________________________________________________________________________
NAME OR NUMBER OF WELL: _________________________________________________________________
FINDING LOCATION: ________________________________________________________________________
LEGAL DESCRIPTION: ___ /4, ___ /4, ___ /4, of Section ______________, T- ___ - ___, R - ___ - ___, I. M. / C. M.,
______________________ County
LATITUDE: _____
_____ ‘ _____ “, LONGITUDE: _____
_____ ‘ _____ “
o
o
TYPE OF PROPERTY: Residential
; Commercial
; Industrial
; City owned property
DEPTH OF WELL: _______ feet
SIZE OF WELL CASING: ___________ inches;
DEPTH OF WELL CASING: _______ feet
NAME OF AQUIFER: ______________________________________________ Confined:
or Unconfined:
Check all the potential sources of contamination listed below (within half a mile for a confined aquifer and
one mile for an unconfined aquifer). In the space provided, indicate how many and distance from the pro-
posed well(s). Also, provide a scaled map showing the location of the well(s) and any listed potential sources
POTENTIAL SOURCE
NUMBER
DISTANCE (FEET)
1. Abandoned oil/gas well
____________
__________________
2. Abandoned water well
____________
__________________
3. Above ground storage tank
____________
__________________
4. Airport
____________
__________________
5. Animal Feedlot
____________
__________________
6. Asphalt Plant
____________
__________________
7. Auto repair/body shop
____________
__________________
8. Barns/sheds
____________
__________________
9. Body contact activities
____________
__________________
10. Cemetery
____________
__________________
11. Chemical production/mixing storage
____________
__________________
12. Confined animal facility
____________
__________________
13. Dairy
____________
__________________
CWHP
July 2013
Oklahoma Department of Environmental Quality
Water Quality Division | Phone: 405-702-8100
Construction Permitting Section
707 N. Robinson, OKC, OK 73102-6010
P.O. Box 1677, OKC, OK 73101-1677
Checklist for Wellhead Protection
APPLICANT'S NAME: ________________________________________________________________________
ADDRESS: _________________________________________________________________________________
CITY: ____________________________________________________ ZIP CODE: _______________________
COUNTY: __________________________________________________________________________________
NAME OR NUMBER OF WELL: _________________________________________________________________
FINDING LOCATION: ________________________________________________________________________
LEGAL DESCRIPTION: ___ /4, ___ /4, ___ /4, of Section ______________, T- ___ - ___, R - ___ - ___, I. M. / C. M.,
______________________ County
LATITUDE: _____
_____ ‘ _____ “, LONGITUDE: _____
_____ ‘ _____ “
o
o
TYPE OF PROPERTY: Residential
; Commercial
; Industrial
; City owned property
DEPTH OF WELL: _______ feet
SIZE OF WELL CASING: ___________ inches;
DEPTH OF WELL CASING: _______ feet
NAME OF AQUIFER: ______________________________________________ Confined:
or Unconfined:
Check all the potential sources of contamination listed below (within half a mile for a confined aquifer and
one mile for an unconfined aquifer). In the space provided, indicate how many and distance from the pro-
posed well(s). Also, provide a scaled map showing the location of the well(s) and any listed potential sources
POTENTIAL SOURCE
NUMBER
DISTANCE (FEET)
1. Abandoned oil/gas well
____________
__________________
2. Abandoned water well
____________
__________________
3. Above ground storage tank
____________
__________________
4. Airport
____________
__________________
5. Animal Feedlot
____________
__________________
6. Asphalt Plant
____________
__________________
7. Auto repair/body shop
____________
__________________
8. Barns/sheds
____________
__________________
9. Body contact activities
____________
__________________
10. Cemetery
____________
__________________
11. Chemical production/mixing storage
____________
__________________
12. Confined animal facility
____________
__________________
13. Dairy
____________
__________________
CWHP
July 2013
POTENTIAL SOURCE
NUMBER
DISTANCE (FEET)
14. Dump/landfill
____________
__________________
15. Fertilizer/pesticide storage-commercial
____________
__________________
16. Fertilizer/pesticide storage-farm
____________
__________________
17. Golf Course
____________
__________________
18. Grain storage bin
____________
__________________
19. Holding pond/lagoon
____________
__________________
20. House
____________
__________________
21. Injection well
____________
__________________
22. Irrigation operation
____________
__________________
23. Machine shop - commercial
____________
__________________
24. Machine shop - farm
____________
__________________
25. Major highway, road, and/or railroad
____________
__________________
26. Military base/depot
____________
__________________
27. Mining
____________
__________________
28. Municipal sewer line
____________
__________________
29. Oil/gas pipeline
____________
__________________
30. Plant nursery and/or greenhouse
____________
__________________
31. Recreational activities
____________
__________________
32. Refinery
____________
__________________
33. Road salt storage
____________
__________________
34. Septic system
____________
__________________
35. Service/Gas system
____________
__________________
36. Sewage plant
____________
__________________
37. Storm sewer
____________
__________________
38. Underground storage tank
____________
__________________
39. Other (specify) ______________________
____________
__________________
______________________
____________
__________________
______________________
____________
__________________
Professional Engineer’s Certification:
I certify that, to the best of my knowledge, all the information provided in this
engineering report form is correct and no significant information necessary for
a proper evaluation of the project has been omitted:
Signature of Professional Engineer: ____________________________________
Date: ____________________________________________________________
Seal
Name of Professional Engineer: _______________________________________
CWHP
State of Oklahoma Professional Engineer No: ____________________________
July 2013
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