State Form 35058 - Application For Construction Permit For Public Water System - 327 Iac 8-3-3(A) - Indiana Department Of Environmental Management Page 6
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9APPLICATION FOR CONSTRUCTION PERMIT FOR
Attachment B
PUBLIC WATER SYSTEM - 327 IAC 8-3-3(a)
Well Construction
State Form 35058 (R5 / 9-98)
Approved by State Board of Accounts 1998
Indiana Department of Environmental Management
Drinking Water Branch
Before review of your well construction permit application can begin, the following must be provided with two (2) copies:
NOTE:
A. A well-site approval
B. Copies of recorded deeds or easements showing control of the land immediately surrounding the well head
C. Data showing 100 years or highest known flood elevations in the area
D. Well design specifications (Attachment B Well Construction)
1. Well Design Specifications
A. How many existing wells are in the well field?
B. What is the rated capacity of each existing wells
C. How many new wells are intended?
if the proposed well is in an existing well field?
D. What type of well will it be? (gravel pack, tubular, radial collector, etc.)
E. What is the estimated depth of the well?
F. Length of casing
Diameter of casing
Casing material
Elevation of the top of the casing
G. If the well is in a pumphouse, how far will the well casing extend above the
H. If applicable, how far does the casing extend into the pump base?
pumphouse floor?
I. How far above final ground surface will the well casing extend?
J. Length of screen
Diameter of screen
Material and slot size of screen
Designed entrance velocity of screen
K. If applicable, what type of grouting
L. To what depth will the well be
M. What type of well pump is intended? (line shaft, submersible, etc.) (attach
material will be used?
grouted?
pump curves)
N. What is each pump's rated capacity and
Anticipated system demand
O. What type of pump lubrication will be used?
total dynamic head (TDH)?
____________GPM
P. What type of provision is made for periodic water level measurements in the well?
Q. Is the discharge piping equipped with the following:
Check valve
Pressure gauge
Smooth-nosed sampling tap
Yes
No
Yes
No
Yes
No
Shut-off valve
Means of measuring flow
Air release/vacuum relief valve
Yes
No
Yes
No
Yes
No
R. Do the specifications describe the test pumping procedures? (if not, please explain)
Yes
No
S. How will power be supplied to the pumps in the event of an interruption to the primary power source?
T. Is this proposed well(s) included in well head protection plan development?
Yes
No
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