WQ-22-S1
Use this survey to assess the risk to groundwater quality posed by the condition of your drinking water well. At the end of each section sum the numbers that correspond to each answer for the section total. When you have completed the survey sum the section totals for the risk assessment score. Refer to Fact Sheet 1 for more information on your drinking water well.
| 1. What is the texture of the soil around your well? | clay (3) loam (2) sand (1) | |||||||||||||||||||||||||||
| 2. At the well site, is the water table or bedrock less than 20 feet from the ground surface? | Yes (1) No (3) | |||||||||||||||||||||||||||
| 3. Is there a depression or sign of soil settlement near or around your well? | Yes (1) No (3) | |||||||||||||||||||||||||||
| 4. Does surface runoff ever reach your well? | frequently (1) occasionally (2) never (3) | |||||||||||||||||||||||||||
| 5. Is the water well upslope from all potential pollution sources? | Yes; all (3) No (1) | |||||||||||||||||||||||||||
6. What is the separation distance between the water
well and each of the following? Skip items not present on your farm.
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Location & Site Characteristics section total _______________
| 7. How was your well constructed? | dug or bucket (1) driven (2) drilled (3) |
| 8. How old is your well? | less than 20 years old (3) between 20 to 70 years old (2) more than 70 years old (1) |
| 9. How deep is your well? | greater than 100 feet (3) 25 to 100 feet (2) less than 25 feet (1) |
| 10. Does the well have a casing? | Yes (3) No or not sure (1) |
| 11. Does the casing extend the full depth of the well? | Yes (3) No or not sure (1) |
| 12. Are there any holes or tears in the casing? | Yes (1) No (3) |
| 13. How far does the well casing extend above the ground surface? | below grade (in pit or basement) (1) between 0 to 11 inches (2) 12 inches or more (3) |
| 14. Are there any cracks or holes in your well cap? | Yes, or well cap is missing (1) No (3) |
| 15. Describe the fit of the well cap. | tight (3) loose (1) |
| 6. Does the well have a vent? | Yes, with screen (3) Yes, no screen (2) No vent (1) |
Construction & Condition section total ____________
| 17. Are there any cross connections between your water supply line and potential sources of contaminated water? | Yes (1) No (3) |
| 18. How many faucet and hose connections have anti-backflow devices? | none (1) some (2) all (3) |
| 19. Are there any unused or abandoned wells on your property that have not been capped or plugged using a procedure approved by the Indiana Department of Natural Resources? | Yes (1) Uncertain (2) No (3) |
| 20. Do you have your water tested on a regular basis? | annually (3) occasionally (2) never (1) |
| 21. Does your water meet state and federal quality standards? | always (3) usually (2) seldom, or not sure (1) |
| 22. Does one or more of the following indicators of your drinking water quality change during wet periods or following a storm: color, clarity, odor or taste? | Yes (1) No (3) |
Maintenance & Testing section total ___________
Add the following totals:
Location & Site Characteristics section total ______ x 3 = ________ Construction & Condition section total _____ x 2 = ________ Maintenance & Testing section total = ________ Survey 1 Score __________ Low: 270 - 150 Moderate:149 - 100 High: 99-30
Click here Fact Sheet 1
Cooperative Extension work in Agriculture and Home Economics, state of Indiana, Purdue University, and U.S. Department of Agriculture cooperating; H.A. Wadsworth, Director, West Lafayette, IN. Issued in furtherance of the acts of May 8 and June 30, 1914. The Cooperative Extension Service of Purdue University is an affirmative action/equal opportunity institution.