"Groundwater Under the Influence of Surface Water - Community Groundwater Exemption Application" - Massachusetts

Groundwater Under the Influence of Surface Water - Community Groundwater Exemption Application is a legal document that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts.

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  • Released on March 1, 2020;
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Download "Groundwater Under the Influence of Surface Water - Community Groundwater Exemption Application" - Massachusetts

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Massachusetts Department of Environmental Protection
Bureau of Resource Protection – Drinking Water Program
City/Town
Community GWUDI Exemption Application
Groundwater Under the Direct Influence of Surface Water
PWS Name/ID#
Instructions
Community public water systems (PWS) must complete this application to determine if their groundwater
source is exempt from microscopic particulate analysis (MPA) testing and the requirements of the Surface
Water Treatment Rule (SWTR). If the source meets the exemption criteria as listed below, it will be
considered “exempt” from all SWTR requirements for GWUDI and classified as a non-GWUDI source.
If you are unable to answer questions on this application or provide the information requested, you should
contact the services of a geologic consultant and/or a Massachusetts registered well driller. PWSs that
cannot meet the exemption criteria because the source has no permanent sanitary seal or have other
physical deficiencies have the option of installing a seal and making appropriate upgrades in order to
meet the exemption criteria.
A. General Information
Important: When
1.
filling out forms
Source Name
Latitude
Longitude
on the computer,
use only the tab
Source ID #
key to move your
cursor - do not
Status:
Active-on line
Active-backup
Emergency
New
use the return
key.
2. Is this source currently filtered?
Yes
No
If yes, describe method and type of filtration:
B. Exemption Criteria For Sand & Gravel Wells
Suppliers whose sand and gravel wells do not meet all of the conditions of one of the Exemption Criteria
(1, 2, or 3) are required to conduct Microscopic Particle Analyses (MPA). Dug wells are evaluated using
the same criteria as sand and gravel wells.
Criterion 1
Is source located 150 feet or more horizontally from a surface water feature?
Yes
No
If yes, how was the distance measured?
Tape
Surveyed
If yes, attach a map, construction plan, or site plan indicating the distance separating the well from
any surface water feature.
Criterion 2
A. Is the well constructed with a properly installed sanitary seal?
Yes
No
If yes, attach the well construction plans and specifications stamped by a Registered Professional
Engineer or signed by a MA registered well driller in accordance with MassDEP construction
guidelines.
Community GWUDI Exemption Application • Page 1 of 3
gwudiex.doc Updated March 2020
Massachusetts Department of Environmental Protection
Bureau of Resource Protection – Drinking Water Program
City/Town
Community GWUDI Exemption Application
Groundwater Under the Direct Influence of Surface Water
PWS Name/ID#
Instructions
Community public water systems (PWS) must complete this application to determine if their groundwater
source is exempt from microscopic particulate analysis (MPA) testing and the requirements of the Surface
Water Treatment Rule (SWTR). If the source meets the exemption criteria as listed below, it will be
considered “exempt” from all SWTR requirements for GWUDI and classified as a non-GWUDI source.
If you are unable to answer questions on this application or provide the information requested, you should
contact the services of a geologic consultant and/or a Massachusetts registered well driller. PWSs that
cannot meet the exemption criteria because the source has no permanent sanitary seal or have other
physical deficiencies have the option of installing a seal and making appropriate upgrades in order to
meet the exemption criteria.
A. General Information
Important: When
1.
filling out forms
Source Name
Latitude
Longitude
on the computer,
use only the tab
Source ID #
key to move your
cursor - do not
Status:
Active-on line
Active-backup
Emergency
New
use the return
key.
2. Is this source currently filtered?
Yes
No
If yes, describe method and type of filtration:
B. Exemption Criteria For Sand & Gravel Wells
Suppliers whose sand and gravel wells do not meet all of the conditions of one of the Exemption Criteria
(1, 2, or 3) are required to conduct Microscopic Particle Analyses (MPA). Dug wells are evaluated using
the same criteria as sand and gravel wells.
Criterion 1
Is source located 150 feet or more horizontally from a surface water feature?
Yes
No
If yes, how was the distance measured?
Tape
Surveyed
If yes, attach a map, construction plan, or site plan indicating the distance separating the well from
any surface water feature.
Criterion 2
A. Is the well constructed with a properly installed sanitary seal?
Yes
No
If yes, attach the well construction plans and specifications stamped by a Registered Professional
Engineer or signed by a MA registered well driller in accordance with MassDEP construction
guidelines.
Community GWUDI Exemption Application • Page 1 of 3
gwudiex.doc Updated March 2020
Massachusetts Department of Environmental Protection
Bureau of Resource Protection – Drinking Water Program
City/Town
Community GWUDI Exemption Application
Groundwater Under the Direct Influence of Surface Water
PWS Name/ID#
B. Exemption Criteria For Sand & Gravel Wells
(cont.)
B. Is the well screen located below a geologic confining layer?
Yes
No
If yes, attach driller/geologist logs indicating the confining layer's presence.
C. Attach the following additional information:
1. Driller/geologist logs for any observation or monitoring wells in the area confirming the
continuity and areal extent of the confining layer.
2. Geologic maps indicating the areal extent of the confining layer and cross sections depicting
the subsurface geology.
3. Describe how and why the confining layer separates the well from any surface water features
located within 150 feet and why surface water induction is unlikely.
Criterion 3
A. Is the top of the well screen 50 feet or more below ground surface?
Yes
No
If yes, attach the well construction specifications or details demonstrating the depth of the screen
below ground level.
B. Has the well been approved by MassDEP to pump or has it historically pumped on average
720,000 gallons per day or less when the well was on line?
Yes
No
If yes, attach the following: Historical documentation compiled in accordance with Method 2 of
Section 4.7 of the MassDEP Guidelines and Policies for Public Water Systems demonstrating
that the source historically has pumped 720,000 gallons per day on average excluding periods of
time during which the source was not in use, or a MassDEP approval letter confirming an
approved pumping rate of 720,000 gpd (500gpm) or below. If this information is unavailable,
calculate water use by multiplying the number of people served by 100 gallons per day.
C. Is the well constructed with a properly installed sanitary seal?
Yes
No
If yes, attach the well construction plans and specifications stamped by a Registered Professional
Engineer or signed by a MA registered well driller in accordance with MassDEP construction
guidelines.
D. Has the groundwater source or system had total or fecal coliform or E. coli violations during the
last three years?
Yes
No
Attach all records from the last three years of all bacterial analyses and if any violations, include
an explanation as to the source of bacteria, if known.
C. Exemption Criteria For Bedrock Wells
Suppliers whose bedrock wells do not meet all of the exemption criteria listed below must conduct
microscopic particulate analyses (MPA). Bedrock wells approved to pump 100,000 gpd or greater, or
that historically pumped at 100,000 gpd or greater, and all springs must conduct MPA.
A. Has the bedrock well been approved by MassDEP to pump less than 100,000 gpd, or has it
historically pumped, less than 100,000 gallons per day?
Yes
No
If yes, please provide historical pumping data.
B. Is the bedrock well 50 feet or more in
Yes
No
depth?
Community GWUDI Exemption Application • Page 2 of 3
gwudiex.doc Updated March 2020
Massachusetts Department of Environmental Protection
Bureau of Resource Protection – Drinking Water Program
City/Town
Community GWUDI Exemption Application
Groundwater Under the Direct Influence of Surface Water
PWS Name/ID#
C. Exemption Criteria For Bedrock Wells
(cont.)
If yes, please attach well construction details and specifications indicating the well depth.
C. Is the well constructed with a properly installed sanitary seal?
Yes
No
If yes, attach the well construction plans and specifications stamped by a Registered Professional
Engineer or signed by a MA registered well driller in accordance with MassDEP construction
guidelines.
D. Is the well 200 feet or more from a surface water feature?
Yes
No
If yes, how was the distance measured?
Tape
Surveyed
If yes, attach a map, construction plan, or site plan indicating the distance separating the well
from any surface water feature.
E. Has the groundwater source or system had total or fecal coliform or E. coli violations during the
last three years?
Yes
No
Attach all records from the last three years of all bacterial analyses and if any violations, include
an explanation as to the source of bacteria, if known.
For All Applications
If this application was prepared by the water supplier with the assistance of an environmental
consultant or well driller, that person must sign below.
Signature
Profession
Affiliation
Phone Number
Date
I hereby certify that my answers to these questions are accurate.
Water Department Official Signature
Phone Number
Date
Please submit the completed Exemption Application Form to your MassDEP regional office.
MassDEP - WERO
MassDEP – CERO
Drinking Water Program
Attn: Mike McGrath
Drinking Water Program
Statehouse West 4
Floor
Attn: Paula Caron
th
436 Dwight St.
8 New Bond St.
Springfield MA 01103
Worcester, MA 01606
MassDEP – NERO
MassDEP – SERO
Drinking Water Program
Drinking Water Program
Attn: Jim Persky
Attn: Mike Quink
205-B Lowell St.
20 Riverside St.
Wilmington, MA 01887
Lakeville, MA 02347
Community GWUDI Exemption Application • Page 3 of 3
gwudiex.doc Updated March 2020
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