Form ECY070-276 "Lummi Peninsula Annual Well Report (For Small Wells)" - Washington

Form ECY070-276 or the "Lummi Peninsula Annual Well Report (for Small Wells)" is a form issued by the Washington State Department of Ecology.

The form was last revised in August 1, 2018 and is available for digital filing. Download an up-to-date Form ECY070-276 in PDF-format down below or look it up on the Washington State Department of Ecology Forms website.

ADVERTISEMENT

Download Form ECY070-276 "Lummi Peninsula Annual Well Report (For Small Wells)" - Washington

1241 times
Rate
4.7(4.7 / 5) 87 votes
Water Resources Program
Lummi Peninsula Annual Small Well Report
For Small Wells (3 or fewer connections)
Within the Lummi Peninsula Case Area
ANNUAL WELL REPORTS ARE DUE NOVEMBER 1st OF THIS YEAR
REMEMBER TO INCLUDE A COPY OF YOUR CHLORIDE ANALYSIS REPORT
***Please keep in mind that well sampling is required to occur in the month of August and
meter reading should occur as close to September 30th as possible***
Name:
Date:
Address:
Phone:
Well Address (If different):
Email:
Well Parcel No.:
Well Tag ID:
Water Right Number (If applicable):
Number of Homes and/or Approved Uses Served:
Name(s) of Owners of Other Homes Served:
Have you had any changes in well operation during the last water year (Oct. 1 – Sept. 30)?
Have you had any problems with your well or water meter during the past water year?
ECY 070-276 (Rev 08-2018) To request ADA accommodation including materials in a format for the visually impaired, call Ecology Water Resources
Program at 360-407-6872. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability may call TTY at
877-833-6341.
Water Resources Program
Lummi Peninsula Annual Small Well Report
For Small Wells (3 or fewer connections)
Within the Lummi Peninsula Case Area
ANNUAL WELL REPORTS ARE DUE NOVEMBER 1st OF THIS YEAR
REMEMBER TO INCLUDE A COPY OF YOUR CHLORIDE ANALYSIS REPORT
***Please keep in mind that well sampling is required to occur in the month of August and
meter reading should occur as close to September 30th as possible***
Name:
Date:
Address:
Phone:
Well Address (If different):
Email:
Well Parcel No.:
Well Tag ID:
Water Right Number (If applicable):
Number of Homes and/or Approved Uses Served:
Name(s) of Owners of Other Homes Served:
Have you had any changes in well operation during the last water year (Oct. 1 – Sept. 30)?
Have you had any problems with your well or water meter during the past water year?
ECY 070-276 (Rev 08-2018) To request ADA accommodation including materials in a format for the visually impaired, call Ecology Water Resources
Program at 360-407-6872. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability may call TTY at
877-833-6341.
Chloride Concentration Measurements
All Small Wells must sample their well water for chlorides in August.
Copies of the lab analysis are DUE TO ECOLOGY WITH THIS REPORT.
August
, 20
Sample Taken:
Chloride Concentration (mg/L):
Other Comments:
Annual Well Reports & Chloride Analyses
should be sent to:
Department of Ecology
Bellingham Field Office
913 Squalicum Way, #101
Bellingham, WA 98225
***Please be sure to include your name, address, phone number,
and well tag ID on all correspondence***
For more information or additional copies of the Lummi Peninsula well report, please visit
Ecology’s website at
https://ecology.wa.gov/Water-Shorelines/Water-supply/Water-rights/Case-
law/Lummi-settlement
If you have any questions or need technical assistance, please contact
Ecology at (360) 255-4400
ECY 070-276 (Rev 8-2018) To request ADA accommodation including materials in a format for the visually impaired, call Ecology Water Resources
Program at 360-407-6872. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability may call TTY at
877-833-6341.
ADVERTISEMENT
Fill PDF online
Page of 2