Form 35058 - Application For Construction Permit For Public Water System And Instructions Page 8

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APPLICATION FOR CONSTRUCTION PERMIT FOR
Attachment B
PUBLIC WATER SYSTEM - 327 IAC 8-3-3
Well Construction
State Form 35058 (R6 / 9-04)
Approved by State Board of Accounts, 2004
Indiana Department of Environmental Management
Drinking Water Branch
Before review of your well construction permit application can begin, two (2) copies of the following must be provided :
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?
A. How many existing wells are in the well field?
B. What is the rated capacity of each existing well if the
C. How many new wells are intended?
proposed well is in an existing well field?
D. What type of well is proposed? (gravel pack, tubular, radial collector, etc.)
D. What type of well is proposed? (gravel pack, tubular, radial collector, etc.)
E. What is the estimated depth of the well?
F. Length of casing
F. Length of casing
Diameter of casing
Casing material
Elevation of the top of the casing
G. If the well will be in a pumphouse, how far will the well casing extend above
G. If the well will be in a pumphouse, how far will the well casing extend above
H. If applicable, how far does the casing extend into the pump base?
the pump house floor?
the pump house floor?
I. How far above final ground surface will the well casing extend?
I. How far above final ground surface will the well casing extend?
J. Length of screen
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
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?
material will be used?
grouted?
pump curves)
N. What is the pump's rated capacity and
Anticipated system demand
O. What type of pump lubrication will be used?
total dynamic head (TDH) of each proposed
pump?
GPM
P. What type of provision is made for periodic water level measurements in the well?
P. What type of provision is made for periodic water level measurements in the well?
Q. Will the discharge piping be equipped with the following:
Q. Will the discharge piping be equipped with the following:
Yes
No Smooth-nosed sampling tap
Yes
No Check valve
Yes
No Presure guage
Yes
No Means of measuring flow
Yes
No Air release/vacuum relief valve
Yes
No Shut-off valve
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?
Yes
No
T. Is this proposed well(s) included in well head protection plan development?

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