If any of the questions in this module are not known due to the

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					3800-PM-WSFR0254d   9/2005
Module 3
 Date Prepared                         COMMONWEALTH OF PENNSYLVANIA
                                  DEPARTMENT OF ENVIRONMENTAL PROTECTION
                              BUREAU OF WATER STANDARDS AND FACILITY REGULATION
Date Revised                          PUBLIC WATER SUPPLY
                                 MODULE 3 – GROUNDWATER SOURCES                        Permit No. (For Department Use Only)



If any of the questions in this module are not known due to the fact that the wells have been in use for a long
period of time and specific information is not available, attach necessary discussion sheets explaining how
these wells comply with the rules and regulations of DEP, Chapter 109, on the basis of the topography and
geology of the area, the sanitary survey, the water quality data and available information on construction of the
well.
A. GENERAL
   1. Was the appropriate regional office consulted prior to the construction of
      this source?                                                                     Yes           No
   2. Has the source been evaluated according to the Surface Water
      Identification Protocol (SWIP) and the results included with the permit
      application?                                                                     Yes           No
   3. Is the aquifer test method clearly outlined in the hydrogeologic report?         Yes           No
    4. Does the hydrogeologic report include static water level(s), pumping water
       level(s), water level(s) at observation point(s) and recovery data?             Yes           No
    5. Was the duration of the aquifer test at least 48 hours?                         Yes           No
    6. Have as-built cross-sectional diagram(s) been provided?                         Yes           No
    7. Are sources constructed to prevent surface and/or subsurface pollution
       from entering?                                                                  Yes           No
    8. Has Module 13 been completed?                                                   Yes           No
B. CASING AND LINER PIPES                                                                                           N/A
    1. Does all casing have minimum weights and thickness as specified in Part II
       of the Public Water Supply Manual?                                              Yes           No
    2. Is the well casing adaptable both to the stresses to which the pipe will be
       subjected during installation and to the corrosiveness of the water?            Yes           No
    3. Is the casing equipped with a drive shoe?                                       Yes           No
    4. Are casing and liner joints welded or threaded?                                 Yes           No
    5. Is protective casing, that is to be grouted in the drill hole or annular
       opening, provided with sufficient guides welded to the casing to permit the
       unobstructed flow and deposition of grout to a minimum thickness of 1.50
       inches?                                                                         Yes           No
    6. Do temporary casings and liners installed without driving have a minimum
       thickness of 0.25 inches?                                                       Yes           No
    7. If the casing has a weight that is less than that specified by AWWA
       standards, is it surrounded by at least 4 inches of concrete, neat cement
       grout or other approved material?                                               Yes           No              N/A
    8. Are all connections between the well and the pump made in such a way as
       to prevent the contamination of the well, regardless of vibration, movement
       of conductors or cables for submersible pumps or other factors?                 Yes           No
    9. Where a watertight connection is not provided on a line shaft pump, is the
       casing inserted into a recess that extends at least 1/2 inch into the base of
       the pump?                                                                       Yes           No              N/A
    10. Is the casing installed in conformity with the applicable construction
        standards set forth in Part II of the Public Water Supply Manual?              Yes           No



                                                          3-1
3800-PM-WSFR0254d   9/2005
Module 3
 Date Prepared                          COMMONWEALTH OF PENNSYLVANIA
                                   DEPARTMENT OF ENVIRONMENTAL PROTECTION
                               BUREAU OF WATER STANDARDS AND FACILITY REGULATION
Date Revised                           PUBLIC WATER SUPPLY
                                  MODULE 3 – GROUNDWATER SOURCES                       Permit No. (For Department Use Only)




C. WELL SCREENS                                                                                                      N/A
    1. Do screen openings provide the maximum amount of open area consistent
       with the strength and the grading of the water-bearing formation or gravel
       pack?                                                                           Yes            No
    2. Do they permit maximum transmitting ability without clogging or jamming?        Yes            No
    3. Are they constructed of material which will not be damaged by the chemical
       action of the groundwater?                                                      Yes            No
    4. Are the screen length and placement such that exposure above the
       pumping water level will not occur?                                             Yes            No
    5. Is the screen designed and installed to permit removal or replacement
       without adversely affecting the water-tight construction of the well?           Yes            No

D. CHEMICAL CONDITIONING                                                                                             N/A
    Have specifications covering method, equipment and controls for chemical
    conditioning of wells been submitted to DEP for approval?                          Yes            No

E. GROUTING                                                                                                          N/A
    1. Does the grout mixture conform to AWWA standards?                               Yes            No
    2. Is all grouting performed by adding the mixture, from the bottom of the
       annular opening upward, in one continuous operation until the annular
       opening is filled?                                                              Yes            No

F. PLUMBNESS AND ALIGNMENT                                                                                           N/A
    1. Is the well tested for plumbness and alignment?                                 Yes            No
    2. Is the test method clearly stated in the specifications?                        Yes            No
    3. Does a 40-foot section of pipe or rigid dummy of the same length have an
       outside diameter not more than 0.50 inches smaller than the diameter of
       the casing or hole being tested, and move freely throughout the length of
       casing or hole to the lowest anticipated pump setting?                          Yes            No
    4. Does the well vary from the vertical less than two-thirds of the smallest
       inside diameter per 100 feet of depth?                                          Yes            No

G. SAMPLES AND RECORDS                                                                                               N/A
    1. Have drill cuttings been obtained at a maximum of 5-foot intervals and at all
       pronounced changes in formation?                                                Yes            No
    2. Have they been submitted to the owner?                                          Yes            No
    3. Has the owner also been supplied with accurate records of the drill hole
       diameters and depths, assembled order of size and length of casings and
       liners, grouting depths, formations penetrated, water levels and aquifer
       tests?                                                                          Yes            No




                                                           3-2
3800-PM-WSFR0254d   9/2005
Module 3
 Date Prepared                          COMMONWEALTH OF PENNSYLVANIA
                                   DEPARTMENT OF ENVIRONMENTAL PROTECTION
                               BUREAU OF WATER STANDARDS AND FACILITY REGULATION
Date Revised                           PUBLIC WATER SUPPLY
                                  MODULE 3 – GROUNDWATER SOURCES                        Permit No. (For Department Use Only)




H. UPPER TERMINAL OF WELL                                                                                             N/A
     1. Does the casing and the protective curbing extend more than 12 inches
        above the pump house floor or well cover?                                       Yes            No
     2. Is the surface of the pump house floor or well cover at least 6 inches above
        the final ground level?                                                         Yes           No
     3. Does the casing pipe terminate at least 18 inches above the final ground
        level?                                                                          Yes            No
     4. Is the top of the pump house floor or well cover at least 3 feet above the
        highest known flood level?                                                      Yes           No
     5. Is the well vented to the atmosphere by means of a downturned vent that is
        at least 1.5 inches in diameter and has a 24-mesh, corrosion-resistant
        screen?                                                                         Yes            No
     6. If the discharge piping is located above ground, are its control valves
        located above the pump house floor?                                             Yes            No             N/A
     7. Is the discharge piping provided with a means to pump to waste without
        being directly connected to a sewer?                                            Yes            No

I.   WATER LEVEL MEASUREMENT                                                                                          N/A
     1. Have provisions been made for periodic measurement of the water level in
        the completed groundwater source?                                               Yes            No
     2. Is the installation made in such a manner as to prevent the entrance of
        foreign material?                                                               Yes            No

J. ABANDONED WELLS                                                                                                    N/A
     Have abandoned wells and test wells been sealed by restoring the controlling
     geological conditions which existed before the wells were drilled according to
     Chapter 7 of DEP's Groundwater Monitoring Manual, available electronically on
     DEP’s Web site at www.dep.state.pa.us ?                                            Yes            No

K. GRAVEL-PACK WELLS                                                                                                  N/A
     1. Is the gravel of the silicaceous type, free of carbonates and foreign
        material?                                                                       Yes            No
     2. Is it washed and disinfected prior to placement?                                Yes            No
     3. Where gravel refill pipes are used, are their upper terminals incorporated
        within the pump foundation and terminated with screwed or welded caps at
        least 12 inches above the pump house floor or concrete apron?                   Yes            No
     4. Is the outer casing or drill hole of such diameter as to provide a minimum of
        1.50 inches of grout around the gravel refill pipes when installed in the
        grouted annular openings?                                                       Yes            No
     5. Are provisions made to prevent leakage of grout to the screen?                  Yes            No




                                                           3-3
3800-PM-WSFR0254d   9/2005
Module 3
 Date Prepared                          COMMONWEALTH OF PENNSYLVANIA
                                   DEPARTMENT OF ENVIRONMENTAL PROTECTION
                               BUREAU OF WATER STANDARDS AND FACILITY REGULATION
Date Revised                          PUBLIC WATER SUPPLY
                                 MODULE 3 – GROUNDWATER SOURCES                      Permit No. (For Department Use Only)




L. RADIAL WATER COLLECTOR                                                                                         N/A
    1. Is the exact location of all caisson construction joints and porthole
       assemblies indicated?                                                         Yes           No
    2. Is the caisson wall substantially reinforced?                                 Yes           No
    3. Is the projection of collectors in areas and at depths approved by DEP?       Yes           No
    4. Are procedures employed which will assure minimum vertical rise?              Yes           No
    5. Is the top of the caisson covered with a watertight floor?                    Yes           No
    6. Are pump openings curbed?                                                     Yes           No
    7. Is projection of pump discharge piping through the caisson walls avoided?     Yes           No

M. INFILTRATION GALLERIES AND SPRINGS                                                                             N/A
    1. Does the source have a watertight cover?                                      Yes           No
    2. Are pump openings curbed?                                                     Yes           No             N/A
    3. Has SWIP monitoring been completed and the data included with the
       permit application?                                                           Yes           No             N/A
    4. Has a water allocation permit been applied for?                               Yes           No             N/A

N. SAND OR GRAVEL WELLS (UNCONSOLIDATED FORMATIONS)                                                               N/A
    When outer casing was used to stabilize the borehole, was it removed during
    grouting?                                                                        Yes           No

O. LIMESTONE WELLS                                                                                                N/A
    Does the casing extend through the overburden and weathered limestone, and
    is it firmly seated into competent bedrock?                                      Yes           No

P. BEDROCK AQUIFER WELLS                                                                                          N/A
    Does the casing extend through the overburden and weathered bedrock, and is
    it firmly seated into competent bedrock?                                         Yes           No

Q. FLOWING ARTESIAN WELLS                                                                                         N/A
    1. Is the construction of flowing artesian wells such that the flow from them
       can be controlled?                                                            Yes           No
    2. Is the protective casing set and the annular space grouted?                   Yes           No
    3. Does the well construction prevent erosion of the confining bed?              Yes           No
    4. Is flow control, consisting of valved pipe connections, watertight pump
       connections, pressure cap, or receiving reservoirs, installed and set at an
       elevation corresponding to that of the artesian head provided?                Yes           No

R. EXISTING WELLS                                                                                                 N/A
    Has DEP been consulted for requirements concerning the reconstruction or
    rehabilitation of existing wells?                                                Yes           No




                                                           3-4
3800-PM-WSFR0254d   9/2005
Module 3
 Date Prepared                         COMMONWEALTH OF PENNSYLVANIA
                                  DEPARTMENT OF ENVIRONMENTAL PROTECTION
                              BUREAU OF WATER STANDARDS AND FACILITY REGULATION
Date Revised                         PUBLIC WATER SUPPLY
                                MODULE 3 – GROUNDWATER SOURCES                       Permit No. (For Department Use Only)




S. DISINFECTION OF WELLS                                                                                           N/A
    1. Will each new well of the water supply, in which water is delivered or
       treated, and any facility which has been out of service for cleaning and/or
       maintenance, be effectively disinfected before being put into service?        Yes            No
    2. Does the procedure used for disinfection conform to the AWWA standards?       Yes           No
    3. Will samples be collected in accordance with these standards before water
       from new systems, or from new parts of existing systems, is furnished for
       consumers’ use?                                                               Yes            No
    4. Will copies of the test results, that are required by the standards, be
       submitted to DEP?                                                             Yes            No




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