Form 3-1 (Return to Document)
Wellhead Protection Inventory Form
Public Water System/Area: ______________________________________________________________
Survey Conducted by: __________________________________________ Date: _____________________
| Commercial/Industrial | Key/Number | Agricultural/Rural | Key/Number | ||
Automobiles |
Body Shops (H) |
Auction Lots (H) | |||
Car Washes (M) |
Boarding Stables (M) | ||||
Gas Stations (H) |
Confined Animal Feeding Operations (CAFOs) (H) | ||||
Repair Shops (H) |
Crops - Irrigated (M)* |
Berries, Hops, Mint, Orchards, Vineyards, Nurseries | |||
| Boat Services/Repair/Refinishing (H) | Greenhouses, Vegetables | ||||
| Cement/Concrete Plants (M) | Crops - Nonirrigated (L) |
Christmas Trees, Grains, Grass Seeds, Hay, Pasture | |||
| Chemical/Petroleum Processing/Storage (H) | Farm Machinery Repair (H) | ||||
| Dry Cleaners (H) | Grazing Animals (>5 large animals or equivalent per acre) (M) | ||||
| Electrical/Electronic Manufacturing (H) | Homesteads - Rural |
Machine Shops (H) | |||
| Fleet/Trucking/Bus Terminals (H) | Septic Systems (L) | ||||
| Food Processing (M) | Lagoons/Liquid Wastes (H) | ||||
| Furniture Repair/Manufacturing (H) | Land Application Sites (M) | ||||
| Hardware/Lumber/Parts Stores (M) | Pesticide/Fertilizer/Petroleum Storage, Handling, Mixing, & Cleaning Areas (H) | ||||
| Home Manufacturing (H) | Others (list) | ||||
| Junk/Scrap/Salvage Yards (H) | |||||
| Machine Shops (H) | |||||
| Medical/Vet Offices (M) | |||||
| Metal Plating/Finishing/Fabricating (H) | |||||
| Mines/Gravel Pits (H) | |||||
| Office Buildings/Complexes (L) | |||||
| Parking Lots/Malls - >50 Spaces (H) | |||||
| Photo Processing/Printing (H) | |||||
| Plastics/Synthetics Producers (H) | |||||
| Research Laboratories (H) | |||||
| RV/Mini Storage (L) | |||||
| Wood Preserving/Treating (H) | |||||
| Wood/Pulp/Paper Processing and Mills (H) | |||||
| Others (list) | |||||
| * Drip - Irrigated crops, such as vineyards and
some vegetables, are considered lower risk (L). LEGEND: Suggested ranking of potential contaminant sources; see Table 3-3 for separate category lists. H = Higher Risks M = Moderate Risks L = Lower Risks |
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Public Water System/Area: ______________________________________________________________________________
Survey Conducted by: ____________________________________________________ Date: ________________________
Residential/Municipal |
Key/Number |
Miscellaneous |
Key/Number |
|
| Airports - Maintenance/Fueling Areas (H) | Above Ground Storage Tanks (M) | |||
| Apartments and Condominiums (L) | Construction/Demolition Areas (M) | |||
| Campgrounds/RV Parks (L) | Historic Gas Stations (H) | |||
| Drinking Water Treatment Plants (M) | Historic Waste Dumps/Landfills (H) | |||
| Fire Stations (L) | Injection Wells/Drywells/Sumps (H) | |||
| Golf Courses (M) | Managed Forests (M) | |||
| Housing - High Density - >1 House/.5 Acres (M) | Military Installations (H) | |||
| Landfills/Dumps (H) | Surface Water - Streams/Lakes/Rivers (L) | |||
| Motor Pools (M) | Transportation Corridors |
Freeways/State Highways (M) | ||
| Parks (M) | Railroads (M) | |||
| Railroad Yards/Maintenance/Fueling Areas (H) | Right-of-Ways - Herbicide Use Areas (M) | |||
| Schools (L) | Underground Storage Tanks |
Confirmed Leaking Tanks - DEQ List (H) | ||
| Septic Systems - High Density - >1/Acre (H) | Decommissioned - Inactive (L) | |||
| Utility Stations - Maintenance Areas (H) | Non-Regulated Tanks - <1100 gallons (H) | |||
| Waste Transfer/Recycling Stations (M) | Not Yet Upgraded or Registered Tanks (H) | |||
| Wastewater Treatment Plants/Collection Stations (M) | Upgraded and/or Registered - Active (L) | |||
| Others (list) | Wells (H) | |||
| Random Dumpsites (M) | ||||
| Sludge Disposal Areas (M) | ||||
| Others (list) | ||||
LEGEND: Suggested ranking of potential contaminant sources; see Table 3-3 for separate category lists. H = Higher Risks M = Moderate Risks L = Lower Risks |
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DEQ-GW\WH5868CF (April 18, 1996)