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Checklist for Drinking Water Source Assessment Horizontal Well Data Sheet Mobile App

Public water systems can use the Checklist for Drinking Water Source Assessment Horizontal Well Data Sheet mobile app with a smartphone or tablet to inspect and document drinking water sources and risk ratings. The app information should be contained in the drinking water source assessment submittal. This app includes a detailed Checklist for Drinking Water Source Assessment Horizontal Well Data. The protection zone for groundwater sources are a set of three circles surrounding the source. (For springs and horizontal wells, if determined to be groundwater sources, the protection zones need not include those portions of the circles down gradient of the source.) The radius of the protection zone is determined in the Delineation section of the assessment and depends upon the aquifer material, well pumping rate, screened interval, and aquifer porosity. At the discretion of the regulatory agency, the water system may request that the regulatory agency prepare a map displaying the source and zones.

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Included Features

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Included Fields

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Public water system:
ID No.
Name of source:
ID No.
Assessment date:
Assessment conducted by:
Water System Contact Name:
Phone #:
Water System Contact Address:
The following information should be contained in the drinking water source assessment submittal.
Delineation of groundwater protection zones
Possible Contaminating Activities (PCA) inventory form
Assessment map with source location and protection zone
Additional maps (optional) (e.
Means of Public Availability of Report (indicate those that will be used)
Notice in the Consumer Confidence Report* (minimum)
Copy in regulatory agency (DHS or LPA) office (minimum)
Copy in public water system office (recommended)
Copy in public library/libraries
Internet (indicate Internet address: )
Other (describe)
*The CCR should indicate where customers can review the assessments.
System Name
System Number
Source of Information (well log, DHS/County files, system, etc)
Organization Collecting Information (DHS, County, System, other)
Date Information Collected/Updated
Source Name
...and More!