2009 Well Water Grant Questionnaire

2009 Well Water Grant Questionnaire--Benton County

Gain General information on County residents' well water systems and groundwater supply/quality.

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What is Your Name and Address of Well (or Approximate Location)?

Do you get your drinking water from a well on your property?

Yes

No

I don't know

Other

If "Other," please explain:

Is there a septic tank on your property?

Yes

No

I don't know

How old is the septic tank?

How many unused water wells do you think are on your property?

Are any of the following within 100 feet of an unused well?

petroleum/heating oil tank

buried gas line

fertilizer/chemical storage or handling area

septic tank/drain field

buried sewer

wastewater lagoon

livestock feeding/confinement area

manure storage area

livestock waste lagoon

poultry building

graveyard

Class V injection well

Are there any streams/ponds within 100 feet of unused well?

Yes

No

I don't know

Is the opening to the unused well greater than 24 inches?*

Yes

No

Other

If "Other," please explain:

None of the Above

When was the unused well drilled?

How deep is the unused well?

Have there been any tests done on your wells?

Do you have any well reports?

Yes

No

I don't know

Are there any unused wells on a neighbors property?

Would you like us to come and assess your groundwater quality?

Yes

No

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