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

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

(Return to Document)

DEQ-GW\WH5868CF (April 18, 1996)