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Home My WebLink About150 Nevers Road - Bark Park Well ApplicationSTATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION PUBLIC WATER SYSTEM GENERAL APPLICATION FOR APPROVAL OR PERMIT [67$ifInstructions/J‘~Z}MW Any regulated public water system (PWS)seeking an approval or permit (refer to list in Section C on following page)must submit this general application to the Department in addition to the applicable specific applications noted in Section C in order for the Department to initiate a review.This general application must be completed by either the administrative official or certified operator for the PWS.Sections A through E must be completed. Incomplete applications will be rejected.This general application form along with the applicable specific applications noted in Section C may be obtained from the DPH Drinking Water Section’s web page by going to the DPH webpage at http://wwwctgov/dph and clicking on the Drinking Water Section Link.Each phase of a multi—phase project requires a completed general application form. 1 of 3 Rev 9/28/07 Section A.Public Water System and Applicant Information PWS Name:”Ta/“ml n F go L4 ’M wm/aLQlyz/ For new PWS indicate proposed name of PWS.A PWSID#will be assigned by the Department for a new PWS Project Name:Z,-‘(2,.C.‘J” Project Address:(f/I m F:Ewe/us;well] PWSID Number:CT PWS Type (select one):B Community D NTNC 'gTNC Town:S K.DPH Project Number (if known): Print Name of PWS Administrative Official or Certified Operator: Title: Address: Phone Number: Fax Number: E-mail Address: Signature of PWS Administrative Official or Certified Operator:DATE Section B.Basis for Requesting Approval or Permit (select all that apply) D Formal Enforcement Action (Administrative Order,Consent Order,Notice of Violation (Civil Penalty))B Violation Identified in Sanitary Survey ReportDWaterQualltyExceedance(select all that apply):D MCL,D Pb/Cu AL,D Secondary MCL,D Other:B Project Identified in Approved Water Supply PlanBFederalorStateGrantsorLoansBDWSRF B STEAP Funds E STAG FundsDCertificateofPublicConvenienceandNecessity(CPCN)D Proactive (system improvements or enhancements) Other:lieu)we l I Rev 9/28/07 2of3 PUBLIC WATER SYSTEM GENERAL APPLICATION FOR APPROVAL OR PERMIT *Section C.Type of-Approval or Permit Requested (select all that apply) Source Treatment Distribution We"Site (must submit Application'for a Public Water System Well Site Approval) Well Construction and Yield'(r er to General Terms for Well Site Development guidance document) Well Water Quality (referto Water Quality Monitoring of Proposed/New Sources of Supply guidance document) B Groundwater Under the Direct Influence of Surface Water (GWUDI)Demonstration Study (refer to Detennination of Groundwater Under The Direct Influence of Surface Water criteria) D Source Improvements (including well pit improvements) E Source Abandonment Permit (must submit Source Abandonment Permit Application) D Water Company Owned Lands Permit-Change in Use (must submit Water Company Land Permit Application & Application Supplement) D Water Company Land Sale or Transfer of a Water Company (must submit Water Company Land Permit Application &Application Supplement) D Recreation Use Permit of Water Company Owned Lands (must submit Permit Application for Recreational Activity on Reservoir) D Storm Water Discharge Permit (must submit detailed Site plan of proposedstormwaterdischarge,refer to RCSA Section 19-13-B32i) B Raw Water Pumping Station D Raw water Transmis§ion Main (must submit Water Main Application) B Sale of Excess Water Permit (must submit Sale of Excess Water Pennit Application) D Other: E Activated Carbon Adsorption D Aeration D Arsenic Removal D Chemical Changes D Chemical Corrosion Control B Contact Time (CT)Evaluation D Disinfection B Chemical D Ultraviolet Light (UV) U Other B Ion Exchange D Iron/Manganese,Iron Bacteria Control D Aeration U Greensand filter D Ion Exchange U Oxidation D Sequestering D Other D M embrane Filtration /Reverse O smosis D pH Adjustment U Chemical U Calcite Filter D Other D Pnot Study D RadiOIOQ-ica'Remova'(Rad 226’ Rad 228,Uranium,Gross Alpha) D Surface Water Treatment Plant- coagulation,flocculation, sedimentation/clarification,filtration D Treatment Residuals/Backwash Wastewater Management D Other: (Bincludes Consolidatio the a d d'Itlon'n Ofof syStem(S) new systems) B Existing Interconnect'o Systemlsn Between (gRaressure R eduction Valves D Pumping Station D Storage Tank pumping B Water stations,Main storage(onl if assocrated facilities, with treatment facilities,sources of supply or funded by a State or Federal grant/loan - must submit water main application) D Other: General ECPCN —Phase 1A B CPCN —Phase tB D CPCN —Phase II D Water Supply Plan B DWSRF Eligibility Application AgreD DWSRF ement ( En P reg-neeringi Award) B DWSRF Full Loan Application B DWSRF Pre-Bid Construction Contract E DWSRF Post-Bid Documents and Information D Sampling Plan (referto DWS web page for instructions,fonn,and guidance) D Water System improvements Study (must submit detailed engineering report)D Other: NOTE:Detailed plans and supporting documents must be submitted at the time of application for all projects Drinking Water Section Use Only Date Stafnped: Assigned Staff Person:Project No: 3 of 3 Rev 9/28/07 PUBLIC WATER SYSTEM GENERAL APPLlCATlON FOR APPROVAL OR PERMIT Section D Prolect Description PrOVide a detailed description of the proposed proiect (orattach summaryfrom engineering report Navaiabie) section Eii‘Finanoia'l Commitment Has a funding source been identified for this project?B Yes B No E N/A if yes,briefly describe the source: Anticipated Start Date of Construction:// STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION Instructions &Information for Completing the Screening Appiication for Water Companies Form Pursuant to Connecticut General Statutes (CGS)Section 16—262m(a),a water company is defined:“As used in this section and section 8-25a,"water company"means a corporation,company,association, joint stock association,partnership,municipality,other entity or person,or lessee thereof,owning, leasing,maintaining operating managing or controlling any pond lake reservoir stream well or distributing plant oLsystem employed for the purpose of supplying water to fifteen or more serVice connections ortwe -'five or more persons on a reguTar Basis’r by w Such proposed water companies must obtain a Certificate of Public Convenience and Necessity (CPCN) prior to any construction of the water system.CGS Section 8-25a requires that:“No proposal for a development using water supplied by a company incorporated on or after October ‘l,1984,shall be approved by a planning commission or combined planning and zoning commission unless such company has been issued a certificate pursuant to section 16-262m.The municipality in which the planning commission or combined planning and zoning commission is located shall be responsible for the operation of any water company created without a certificate after October 1,1984." This form is intended to determine if the proposed project will result in the creation of a new water company,as defined in CGS Section 16-262m(a).lf the project will result in the creation of a new water company then the applicant must apply for a CPCN.Complete the form and submit to the CT Department of Public Health (DPH)Drinking Water Section (DWS),as indicated at the bottom of the form. Section 1 —Basic Information The number of service connections is the number of independent structures or housing units that are proposed.Separate the total number and indicate in the appropriate space how many of each type of connection. >“Residential”refers to housing facilities (homes,apartments,condos —permanent living quarters) >“Non-Residential”refers to businesses.These include schools,day care facilities,food service establishments,offices,etc.(Le.anything that is not residential.) Section 2 —Proposed Facility Information The “Proposed Facility Information”will be used to determine the applicability of the water company definition to the proposed project. >“Name of Proposed Facility”will be used to identify the facility in correspondence from this office. >“Total projected daily population to be served”is the anticipated number of persons to have water made available to them on a daily basis This number is the average based on the maximum 60 days of usage over the course of a one year period >“BUIIding CapaCIty Is the maXImum number of indIVIduals that Will be allowed by the occupancy permit >“Non-transient population”is the anticipated number of the same persons to occupying the completed facility,such as students and/or employees.If a school,separate out the number of students and employees. >“Approved/Proposed Daycare Capacity”refers to the number of children that has been or will be submitted to Daycare Licensing for approval (if applicable).If you have specific questions with respect to childcare facilities,please refer to the DPH Child Day Care Licensing program at: http://wvwvdgh.state.ct.us/BRS/Day Care/day care.htm Page 1 of 2 Instructions for Screening Application for Water Companies form Final:10/12/05 y STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION >“Subsurface sewage disposal system capacity”is the proposed/approved capacity (in gallons perday—GPD)of the on-site disposal system (if applicable).Indicate if served by sanitary sewer. >“Number of days per year facility will be open”refers to the total number of days water will be made available to the public during the calendar year. >For the “Type of Facilities”circle each that applies.If not found on the list,circle ‘other’and specify in the space provided.Types of facilities can include (but are not limited to):shopping centers,restaurants,childcare operations,schools,or highway rest areas.Information regarding the regulation of childcare facilities can be found from the DPH Child Day Care Licensing program at:http://www.dph.state.ct.us/BRS/Day Care/day care.htm Section 3 —Property Owner Information List the name and other information of the property owner of the facility.If the property owner is not an individual,a Legal Contact (see definition below)must also be noted in the space provided.This individual will be legally responsible for the possible drinking water company,and will sign the form.This person must have familiarized themselves with the applicable state and federal regulations.Please pay close attention to Regulations of Connecticut State Agencies (RCSA)Sections 19-13-B102 and 19-13- B51.AII regulations enforced by the DWS can be found at: http://www.dph.state.ct.us/BRSNVater/DWD Regs/DWD Regshtm A Legal Contact is defined as:individual(s)who are partners,officers,directors,etc.of the company and have the responsibility of handling legal matters for the company. Section 4 —Water Main Extension Feasibility Information ls the facility within an area with a convened Water Utility Coordinating Committee? The state has been divided into seven management areas for purposes of establishing Water Utility Coordinating Committees (WUCC).If the proposed water system is located in an area that has a convened WUCC,a letter must be submitted containing the necessary information as indicated on the application form.If no WUCC has been convened yet for that area,a letter(s)must be submitted as indicated on the application form.Information on the WUCCs along with a map and a list of contact persons is available on the DWS website at:http://www.dph.state.ct.us/BRSNVaterNVUCC/index.htm. The CGS concerning the WUCC are Sections 25-33d through 25-33j and can be found at: http://www.cga.ct.gov If the location of the proposed facility is in an area with a convened WUCC,and the Exclusive Service Area (ESA)provider cannot or will not serve the facility,that WUCC must make a recommendation as to how water service should be supplied to the facility.That determination must be submitted with the screening application form. If the location of the proposed facility is in an area with no convened WUCC,refer to the following DPUC webpage for a list of water systems serving greater than 1000 persons or having greater than 250 service connections:httg://www.state.ct.us/DPUC/consumerNVATER.htm Once the screening application form has been completed,it must be signed and dated by the property owner/legal contact.The completed form must then be submitted to the DWS along with all other required information as noted.The DWS will review all submitted materials and a determination made as to whether the proposed project will result in the creation of a water company or if a water main extension is a feasible option. Page 2 of 2 Instructions for Screening Application for Water Companies form Final:10/12/05 Page 1 ofl STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH &DEPARTMENT OF PUBLIC UTILITY CONTROL SCREENING APPLICATION FOR WATER COMPANIES Pursuant to CGS Sections l6-262m &8-25a The pulpose of thls form ls to determlne 1f the proposed prOJect W111 result 1n the creatlon of a new water company,as defmed 1n CGS Sectlon 16 262m(a)If the prOJect W111 result 1n the creatlon of a new water company then the apphcant must apply for a Certlflcate of Pubhc Convemence and Necess1ty (CPCN) Section l:Basic Information Section 4:Water Main Extension Feasibility Information Is the facility within an area with a convened Water Utility Coordinating Committee (WUCC)?B YES D NO E]IfYES,submit a letter from the water utility which holds the exclusive service area,expressing its willingness or unwillingness to own,manage,and operate water service to the project.o If the water utility is willing to serve,the letter submitted shall include the proposed manner of service and cost,via main extension or satellite ownership. o If the water utility is unwilling to serve,the letter shall justify the causes and factors for its inability to reasonably serve the proposed project,and shall also be accompanied with a letter from the WUCC recommending the approval of the proposed public water supply system. If N0,are there any regulated community water systems serving >1000 persons or having >250 service connections within one linear mile of the applicant’s project?D YES D NO If YES,submit a letter(s)expressing the system(s)’s willingness or unwillingness to serve the project via a water main extension.The letter must include cost to the applicant for all materials,etc.and whether additional supply and/or storage and booster facilities will be required to provide adequate water service. Signature of Property Owner/Legal Contact:Date Submit completed form to Capacity Review &Standards Unit,CT-DPH,Drinking Water Section,410 Capitol Ave.,MS#5 IWAT, P O Box 340308 Hartford CT 06134 0308 FOR DWS USE ONLY ‘"" W111 proposed project resut 1n a new water companl yuthorizedtoproceed1thCPCNIYesDNo Date of determinati DWS Proj ect #: Revis‘edf:1 0.7 z05 : o Number of proposed service connections (indicate all that apply):Residential Non-Residential Section 2:Proposed Facility Information Name of Proposed Facility Total projecteddailypopulation to be served Proposed building capacity Subsurface sewage disposal system capacity (GPD)(ifapplicable)Property Address Non-transient population Approved/proposed Daycare capacity Number of days per year facility will be openCityStateZIPCode Type of Facilities (Check all that apply)DSchool DDay Care DCampground DFood Service BResidential B Medical/Dental DProfessional Office DYouth Camp DGas Station DRetail DManufacturing DOther—specify: Section 3:Property Owner Information Name Legal Contact Person (if owner is not an individual) Telephone &Fax Address E—mail Address City State ZIP Code STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION InstructiOns &Information for Completing the NON-COMMUNITY Certificate of Public Convenience and Necessity (CPCN)Application Forms This informational document is intended as a reference guide for completing the Non- Community Certificate of Public Convenience and Necessity (CPCN)Application Forms. Included here will be an explanation of each section of that form and links to additional information found on the web. New proposed water systems and existing public water systems undergoing expansion may be required to apply for a CPCN,per Connecticut General Statutes (CGS)Section 16-262m,which can be found at:http://www.cga.ct.gov.This is commonly referred to as the “certificate process.” The Department of Public Health (DPH)and the Department of Public Utility Control (DPUC)jointly administer the CPCN process.The DPUC is the responsible agency for issuance of the joint Certificate at the appropriate time.For purposes of Non-Community water systems,the DPH will solely review all phases of the project and request issuance of the Certificate from the DPUC. The entire CPCN application is separated into three phases:Phase I-A,Phase I-B,&Phase ll. Only complete one phase at a time.Do not move on to a subsequent phase until the preceding phase has been formally reviewed by the DPH —Drinking Water Section (DWS)and written confirmation has been received to continue the process.Approval of the initial phases shall not in and of itself guarantee the later issuance of a CPCN. This document is divided into sections to match the corresponding phase application forms. Please refer to the appropriate section when completing that part of the CPCN application. A completed General Application for Approval or Permit form must be submitted with each phase application of the CPCN.The General Application form can be found at: http://www.dph.state.ct.us/BRSNVater/utility/Forms/Forms.htm There are a number of webpage links in this document,most to specific pages.The DWS homepage can be found at:http://wwwdgh.state.ct.us/BRS/water/DWD.htm Other helpful information: introduction to the Drinking Water Section: http://www.dph.state.ct.us/BRSNVater/Utility/wss info intgdf Glossary &Terms: http://www.dph.state.ct.us/BRSNVater/Utility/31—icq|oss terms.pdf If,after reviewing all the information provided in this document,you still have questions,please caii the Drinking Water Section @ 860-509-7333 during the normal office hours of 8:30 am —4:30 pm Monday through Friday. Page 1 of 10 NC CPCN application instructions &information Revised:10/19/05 STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION ACRONYMS USED IN THIS DOCUMENT C or CWS CGS CPCN CRS DEP DPH DPUC DWS EPA ESA GPD NRCS NTNC PWS PWSID RCSA SWP TNC USDA USGS WUCC Page 2 of 1O NC CPCN application instructions &information Revised:10/1 9/05 Community Water System Connecticut General Statutes Certificate of Public Convenience and Necessity Capacity Review &Standards Unit (within the DWS) Connecticut Department of Environmental Protection Connecticut Department of Public Health Connecticut Department of Public Utility Control Drinking Water Section (within the DPH) United States Environmental Protection Agency Exclusive Service Area Gallons per Day National Resources Conservation Service (part of USDA) Non—Transient Non-Community water system Public Water System Public Water System Identification Number Regulations of Connecticut State Agencies Source Water Protection Unit (within the DWS) Transient Non-Community water system United States Department of Agriculture United States Geological Survey Water Utility Coordinating Committee STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION PHASE l-A The Phase I-A application requirements are for review of the proposed sources of supply to serve the proposed project (i.e.well site locations).This part of the process also reviews and evaluates whether the developer of the proposed project understands the responsibility and requirements involved with a public water system.That is,whether there is the ‘capacity’to develop and maintain a viable public water system that will remain in compliance with all applicable regulations once the water system is operational. “DPH-DWS Project #"is the tracking number assigned to the project by the DWS.This number must be referenced on all documents submitted with respect to this project.The DPUC will assign a “Docket #”to the project which must also be referenced.These two numbers are independent but both necessary. This form is for use with a proposed new public water system and expansion of an existing system. If expansion,write in the PWS name and Public Water System Identification Number (PWSID)of the system.lf a new system,leave blank.A number will be assigned at a later date.If expansion is on the same parcel of land,or an abutting parcel with the same owner,but the new construction will not be connected to the existing water system,then the new facility/building will be considered a new public water system. All items required by the Phase I-A application form must be submitted.Check off each that is included with the submission. Water Company Screening determin Enclose a copy of the letter from the DWS review of the Water Company Screening materials. Application Fee (#2 on application for MA I T%L,/I, Per CGS 16 262m a fee of $100 00 is rel :k must be of made the applicationpayable to “Treasurer, &materials State to Initiate of Cor a OU g {,1 .J/éx/J is???. pplication with a copy & materials to DPH,without the fee. Application for a Public Water Syst 3n form) Each proposed well must have a separate,completed well site application submitted for review. Note that the site map submitted for a proposed well site must be certified (stamped,etc.)by either a registered Professional Engineer (P.E.)or Land Surveyor (L.S.).Information relative to the well siting process,including general terms for well site development,guidance on well location relative to the 100-year flood level,required water quality testing for new sources,yield test logs,and the application form can be found at: www.dph.state.ct.us/BRS/Water/utility/Forms/Forms.htm#Well Site Questions regarding completion of that application should be directed to the DWS’s Source Water Protection (SWP)program: http://www.dph.state.ct.us/BRS/water/Source Protection/source protectionhtm Page 3 of 1O NC CPCN application instructions &information Revised:10/1 9/05 STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION Quantity of Water Necessary (#4 on application form) The anticipated water demand of the proposed facility must be determined.There must be enough water available to provide an adequate supply at all times including periods of average and peak demands.Complete Attachment #1 —Averaqe Daily Demand Calculation Worksheet for Item #4 & submit with Phase I-A materials. Control of Pollution Sources (#5 on application form) The surrounding area must be evaluated for identification of existing and/or potential pollution sources.A plan for control of any sources found must be developed and submitted.A guidance document regarding certain sources of pollution can be found at: www.dph.state.ct.us/BRS/Water/utility/Forms/Forms.htm#Wel|Site Topographic Map (#6 on application form) A topographic map must be submitted that shows the location of the proposed project and its relationship to the surrounding area. TMF Capacity Evaluation (#7 on application form) Part of the CPCN process requires evaluation on the basis of “capacity development”purposes for technical,managerial,and financial capacity.The capacity evaluation questions are intended to be part of that review.If you need additional space to answer the questions,attach separate sheet(s) of paper and note on the form. It is a significant responsibility to own and/or operate a public water system.There are many important issues that require knowledgeable oversight in order to maintain compliance with all the applicable state and federal regulations.The DWS strives to consistently enforce all those regulations for the protection of public health in the state.Please refer to the brochure“introduction to the Water Business”found at: http://wwwdph.state.ct.us/BRS/water/Utility/intro water.gdf The completed ‘Technical,Managerial,and Financial (TMF)Capacity Evaluation’form (Attachment #2)must be signed and dated by the property owner/legal contact and submitted along with other materials required under Phase I-A. What is Water System Capacity? The federal Environmental Protection Agency (EPA)defines Water System Capacity as the ability to plan for,achieve,and maintain compliance with applicable drinking water standards. Capacity has three components:technical,managerial,and financial.Adequate capability in all three areas is necessary for a system to have “capacity.” Managerial capacity is the ability to own and operate a public water system.This includes staffing and organization and adequately planning for current and future needs.There must also be an understanding and implementation of regulatory responsibilities. Page 4 of 10 NC CPCN application instructions &information Revised:10/1 9/05 STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION Technical capacity is the ability to maintain adequate supply and infrastructure and to implement the necessary requirements to maintain that adequacy. Financial capacity is the ability to obtain sufficient revenues,remain credit worthy,maintain fiscal management and control,and financially maintain and operate the water system. These three categories are interrelated in the overall operation of a water system through short—and long-term planning,assurance of sufficient supply and infrastructure for the future, and meeting regulatory responsibilities in order to provide safe and adequate drinking water. What is Capacity Development? The EPA describes Capacity Development as the process of water systems acquiring and maintaining adequate technical,managerial,and financial capabilities to enable them to consistently provide safe drinking water.In the State of Connecticut,that also includes the ability to maintain compliance with all applicable state and federal regulations. Additional information on small water systems and capacity development is available from the federal Environmental Protection Agency (EPA):http://wwwepa.gov/safewater/smallsys.html General Questions (question #’s 1-4) These questions are designed to determine the basic level of background the owner has with the ownership,maintenance,or operation of a business and/or water system. Introduction to Water Business brochure: httQ://www.dph.state.ct.us/BRS/water/Utility/intro waterpdf Regulations enforced by the DWS: http://www.dph.state.ct.us/BRS/Water/DWD Reqs/DWD Regshtm CPCN Phase l-A approval will not be granted by the DWS until it can be demonstrated that there is adequate managerial capacity. Water System Operation (question #’s 5-15) The answers to the questions in Section 4 will further provide the DWS with an understanding of the familiarity of the owner with drinking water statutes and regulations. A property to be developed with an onsite potable drinking water system must be able to provide adequate locations for the wells and maintain proper source protection for them. Please refer to the SWP Program at: http://www.dph.state.ct.us/BRS/water/Source Protection/source protectionhtm Additional information can be found from the well site application and RCSA Section 19-13-B5ta —m: http://wwwdgh.state.ct.us/BRS/water/Utility/Forms/well site applicationpdf(wellsite); http://wwwdph.state.ct.us/phc/docs/20 Water Supply Wells and S.doc (RCSA 19-13-351 ). Page 5 of 10 NC CPCN application instructions &information Revised:10/1 9/05 STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION New businesses generaHy require some type of permitting from the town/jurisdiction in which it will be located.If known,list the necessary approvals and which,if any,have been obtained. An experienced water system design professional should be consulted/hired for the design and/or development of the water system. In answering question #9,use the following definitions. Public Water System classification types,per RCSA Sec.19-13-3102: v A Community Water System (C)is a public water system that serves are least 25 residents. Examples include residential subdivision with common wells,apartment building,condo complex,residential school,etc. v A Non-Transient Non-Community Water System (NTNC)is a public water system that is not a community water system and that regularly serves at least 25 of the same persons over six months per year.Examples include day schools,restaurants with >25 employees, businesses with >25 employees,etc. v A Transient Water System (TNC)is a non-community water system that does not meet the definition of a non-transient non-community water system.Examples include rest areas, restaurants or businesses with <25 employees,etc. The above definitions were taken from RCSA Section 19-1 3-B1 02: http://wwwdph.state.ct.us/phc/docs/31 Public Drinking Water Qu.doc A diagram is available at:http://wwwdgh.state.ct.us/BRS/water/Consumer/PWS.htm All proposed new systems that meet the definition in RCSA Sec.16-262m-1(a),mustfollow RCSA Sec.16-262m-1 through m-9.The DWS and DPUC jointly administer these regulations. They can be found on the DPUC website at: http://www.dpuc.state.ct.us/DPUCINFO.nsf/e4f70c6b591 cec9885256b43005aec9c/463682dOd 71 b52c785256bea005b0d55?OpenDocument All NTNC public water systems are required to contract with a certified operator.Information on the DWS Operator Certification program can be found at: http://wwwdph.state.ct.us/BRSNVater/Op Cert/op cert.htm Water Quality monitoring requirements for public water systems can be found in RCSA Section 19-13-B1 02(e).This section includes the water quality standards that must be met by all publicwatersystems:http://wwwdph.state.ct.us/BRSNVater/DWD Regs/DWD Regshtm Also refer to the document outlining required water quality tests for new sources of supply (under information for well site approval)at: http://www.dph.state.ct.us/BRSNVater/utilitv/Forms/Forms.htm#Well Site All water quality monitoring that is conducted and submitted for compliance purposes must be analyzed by a lab certified in the State of Connecticut.information on Connecticut-certified water testing laboratories can be found from the DPH Environmental Laboratory Certification Program:httg://www.dph.state.ct.us/BRS/Environmental Lab/environmental laboratoryhtm The EPA is always working on new regulations for public water systems.Information on proposed new rules and existing rules can be found at: http://www.epa.qov/safewater/index.html Page 6 of 10 NC CPCN application instructions &infomation Revised:10/1 9/05 STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION It is not uncommon for a small water system to have to treat the groundwater in some way, whether to maintain compliance with drinking water standards or for aesthetic reasons. Common types of treatment are pH adjustment and iron/manganese removal.If treatment is necessary,specific operator certification requirements must be met (go to http://wwwophstatect.us/BRSNVater/Op Cert/op cert.htm for more information). CPCN Phase l-A approval will not be granted by the DWS until it can be demonstrated that there is adequate technical capacity. Financial Capacity Information (question #’s 16-27) This section evaluates the financial capacity of the owner to maintain and operate the water system in adequate condition for the short-and long-term.It is vital to the maintenance of every water system to have a financial plan. A significant financial commitment is required to develop and/or own a public water system. Initial expenses include,but are not limited to,drilling the wells,testing for water yield, permanent installation of properly sized pump and proper wellcap,and water quality testing. Annual expenses include,but are not limited to,routine water quality monitoring,supplies, contracting with a certified operator,energy costs,necessary chemicals,other operational expenses,possible loan repayment,money set aside for emergencies,etc.All costs must be taken into account! The following are some organizations that offer technical,managerial,and/or financial assistance for development of drinking water systems or businesses. Rural Community Assistance Program:www.rcap.org Atlantic States Rural Water and Wastewater Association:www.asn/vwa.org EPA Environmental Finance Program:www.epa.gov/efinpage EPA Region 1 small business assistance:www.epa.gov/region1Ismallbusiness/index.html United States Department of Agriculture:www.usda.gov/rus/water National Environmental Services Center:www.nesc.wvu.edu Refer to the Introduction to the Water Business brochure for additional links: http://www.dph.state.ct.us/BRS/water/Utility/intro waterpdf CPCN Phase l-A approval will not be granted by the DWS until it can be demonstrated that there is adequate financial capacity. Groundwater Quality and Soil Classification (#8 on application form) A description of the groundwater quality and subsurface soils for the project area must be submitted.The CT Department of Environmental Protection (DEP)classifies the groundwater in the state.Information on soil classifications can be found through the United States Department of Agriculture (USDA)Natural Resources Conservation Service (NRCS). DEP Bureau of Water Management:http://wwwdep.state.ct.us/wtr/prgactivhtm Page 7 of 10 NC CPCN application instructions &information Revised:10/1 9/05 STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION DEP groundwater quality:http://www.dep.state.ct.us/wtr/wq/wqsinfo.htm USDA:httQ://www.usda.gov/wgs/gortal/usdahome NRCS:httg://www.nrcs.usda.gov/ Proposed Water System Certified Operator Information (#9 on application form) Non-Transient Non-Community public water systems are required to have a Certified Operator overseeing the system.This is required pursuant to RCSA Sections 25-32-7a thru 14.The DWS Operator Certification program should be contacted with any questions relating to water system operators.If no operator has been designated at this time,please note if one is “to be determined.” DWS Operator Certification program:http://wwwdphstate.ct.us/BRS/water/Op Cert/op certhtm Operator Certification regulations: http://www.dph.state.ct.us/phc/docs/1 5O Qualifications of Opera.doc Letter from Town Planning Department (#10 on application form) Are there any proposed building sites within one mile of this property?Provide a detailed letter from the town’s planning department indicating any known probable future building areas within one mile of this property. Once the CPCN Non-Community Phase I-A application form has been completed,and you (property owner/legal contact)have familiarized yourself with all the requirements of owning a water system,it must be signed and dated.The ESA provider or regulated water company that will own and operate the proposed water system (as &if applicable)must also sign and date the completed application.The completed Phase I-A application form must then be submitted along with all other required information as noted. A proposed new water system must demonstrate adequate technical,managerial,and financial capacity before that system can be approved. Approval of Phase l-A shall not in and of itself guarantee the later issuance of a CPCN. Page 8 of 10 NC CPCN application instructions &infonnation Revised:10/1 9/05 STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION PHASE I-B If approval was given to proceed following review of the Phase l-A application,the next step in the process is to submit the requirements of Phase I-B.The Phase I-B requirements are for review of the developed sources of supply.This part of the process reviews the well construction,well water yield,and water quality.All sources must have satisfactory water quality and be able to supply a sufficient amount of water to meet the system requirements. Phase l-A determination letter (#1 on application form) Enclose a copy of the letter from the DWS indicating the determination made following review of the Phase l-A materials. Well Driller’s Completion Report (#2 on application form) After a well is developed (i.e.drilled),the licensed well driller is required to submit a “Well Completion Report”to the applicable local health department.A copy of that report must be submitted for each well that was drilled. Yield Test Results (#3 on application form) Following development of a well,it must be tested to determine the amount of water available. This is done by pumping the well as noted on the requirements outlined in the Phase l-A approval. The results of the yield test will be review by this office.A well must have adequate yield in order to be utilized. Water Quality Test Results (#4 on application form) Water quality samples must be taken from any new well and tested for the parameters as noted in the Phase l-A approval.This office will review the results of the water quality tests.A well must have satisfactory water quality in order to be utilized. Estimated Cost of Water Facilities to be Constructed/Expanded (#5 on application form) A water system is a significant investment.The cost of all components necessary to deliver adequate,potable water can be quite large.The estimated itemized cost is requested to determine if the applicant is aware of the cost of components associated with a PWS. Once the CPCN Non-Community Phase l-B application form has been completed,it must be signed and dated.The ESA provider or regulated water company that will own and operate the proposed water system (as &if applicable)must also sign and date the completed application. The completed Phase l—B application form must then be submitted to the DWS along with all other required information as noted. Approval of Phase l-B shall not in and of itself guarantee the later issuance of a CPCN. Page 9 of 10 NC CPCN application instructions &information Revised:10/19/05 STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION PHASE II If approval was given to proceed following review of the Phase -B application,the next step in the process is to submit the requirements of Phase ii.The Phase ii requirements are for review of the design of the water distribution system.This part of the process reviews the storage,pumping facilities,distribution piping,and if necessary,treatment facilities. All plans and specifications for non-community public water systems must be designed in accordance with the “interim Technical Standards for Non—Transient Non-Community and Transient Non-Community Water Systems”document.This can be obtained upon request. Phase l-B determination letter (#1 on application form) Enclose a copy of the letter from the DWS indicating the determination made following review of the Phase l-B materials. Plans and Specifications for the Project (#2 on application form) The plans and specifications for all distribution system components of the water system must be submitted for review.This includes storage tanks,pumping facilities,possible treatment systems, distribution system piping,and other appurtenances.If treatment is proposed,a completed Water Treatment Plant Classification form must also be submitted.This form can be found at: http://wwwdph.state.ct.us/BRSNVater/utility/Forms/Forms.htm Plan for Action and Proper Notification or Authorities (#3 on application form) Pursuant to RCSA Section 19-13-B46,a PWS must immediately notify this office in the event of an emergency,whether it is related to the security of the water system,the treatment facilities,source of supply,or other incident that may impair the quality or sufficiency of the water supply.The applicable local heath department must also be notified.A PWS must then also have a plan of action for how to handle the different types of situations that may be encountered that require a prompt response. Proposed Operator (#4 on application form) Pursuant to RCSA Sections 25—32-7a thru 14,Non-Transient Non-Community public water systems are required to have a Certified Operator overseeing the system.A completed “Operator Verification from must be submitted,which can be found on the DWS Operator Certification program webpage:http://www.dph.state.ct.us/BRS/water/Op Cert/op cert.htm Operator Certification regulations: http://wwwdgh.state.ct.us/ghc/docs/150 Qualifications of Operadoc Once the CPCN Non-Community Phase ll application form has been completed,it must be signed and dated.The ESA provider or regulated water company that will own and operate the proposed water system (as &if applicable)must also sign and date the completed application. The completed Phase ll application form must then be submitted to the DWS along with all other required information as noted. Upon approval of Phase ii,DWS will recommend to DPUC that a CPCN be issued. Page 1O of 1O NC CPCN application instructions &infonnation Revised:10/1 9/05 Non-Community CPCN Phase I-A (Page 1 of 1) STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH &DEPARTMENT OF PUBLIC UTILITY CONTROL APPLICATION FOR A NON-COMMUNITY CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (CPCN)Pursuant to CGS Sec.16-262m This application process is separated into three phases —Phase I-A,Phase I—B,&Phase II.Only complete one phase at a time.Do not move on to a subsequent phase until the Department of Public Health —Drinking Water Section has formally reviewed the preceding phase and written confirmation has been received to continue the process. PHASE I-A (Non-Communitv) (Facility name as on the water company screening application) The following must be submitted for the Phase I-A Non-Community CPCN review,as required per the letter of determination of water company screening application review (check off each that is included with this submission): D 1.Copy of the DWS’s letter of determination of water company screening application review 2.Application fee of $100.00 (check made out to ‘Treasurer,State of Connecticut’) 3.Completed ‘Application for Public Water System Well Site Approval’for each proposed well 4.Evaluation of the quantity of water necessary to provide adequate supply (use Attachment 1 —ADD calculation worksheet) 5.Plan for controlling pollution sources that might affect the we11(s) 6.Topographical map showing the relationship and location of the proposed project to the surrounding area 7.Completed “TMF Capacity Evaluation”questionnaire (see Attachment 2) Attach an additional sheet(s)of paper as necessary to properly and fully answer all questions.referencing question numbers. 8.Description of the groundwater quality as classified by the CT Department of Environmental Protection and subsurface soils as classified by the United States Department of Agriculture —Natural Resources Conservation Service,for the proj ect area 9.Name and certificate number of proposed/existing water system certified operator (if applicable) 10.Provide a detailed letter from the town’s planning department indicating any known probable future building areas within one mile of this property Signature of Property Owner/Legal Contact:Date DDE DDE B E D Signature of ESA provider (if applicable):Date: (If no ESA provider:signature of representative of regulated water company that is to own &operate the proposed water system,if applicable) rz N eed With‘P‘I—B‘:[3 Y Dateofdetermmation:‘".'v '.’‘1.LR‘evised:10/6/05’'' : Authoied c lias .es DPH-DWS PROJECT #:(as assigned by this office) DPUC DOCKET #:(as assigned by DPUC) Facility/PWS Name:PWSID:CT (if applicable) STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER DIVISION APPLICATION FOR A PUBLIC WATER SYSTEM WELL SITE APPROVAL PLEASE COMPLETE ALL ITEMS ON THIS APPLICA TION Applicant Name:Public Water System (PWS)Name]: Address: Pws 1D Number‘:CT Phone Number: Applicant’s Affiliation With PWS: Name of Consulting Engineer (If applicable): Company Name: Address: Phone Number: 1.For existing systems only.If new system,a PWSID#will be assigned.For new systems indicate proposed name of system. SECTION A.WELL INFORMATION l.Name of Licensed Well Driller (must be licensed in CT): 2.CT License Number: 3.Address:Phone Number: 4.Purpose ofNew Well (check one): ()New source ()Replacement Well ()Supplemental Well ()Back—up Well 5.Name of Proposed Well:Type:Bedrock ()or Gravel Packed() 6.Desired Yield (check one):()<10 gallons per minute (gpm)()10-50 gpm ()>50 gpm 7.Town where proposed well will be drilled: 8.Indicate closest town road or intersection: 9.Latitude and Longitude of proposed well site:Lat:N Long:W 10.Is proposed well site staked or marked?()Yes ()No ll.List any previous federal,state or local permits or certificates that have already been issued for the proposed well: SECTION B.WELL SITE CHARACTERISTICS 2.The public water system must have full ownership or control (sanitary easement)of the entire sanitary radius for a well with a proposed withdrawal rate greater than 50 gpm per RCSA Section l9—l3-B51d(c)(3).If the proposed well is partofaCertificateofConvenienceandNecessityproject,the public water system must have full ownership or control of the entire sanitary radius regardless of the proposed withdrawal rate per RCSA Section 16-262m-8(e)(l)(D).Proof of ownership/easement including a map of the land owned by the public water system must be included with this application.If the public water system does not have full ownership or control of the sanitary radius,indicate below how ownership or control will be obtained: Note:A well use approval will not be issued unless proof of ownership or control of the sanitary radius is received by the Department.Although ownership or control of the sanitary radius for a non 16-262m Certificate well with a proposed withdrawal rate less than 50 gpm is not required,it is strongly recommended. 3.Are there any adjacent public and/or private active/inactive well(s)located near the proposed well site?If yes,indicate name(s)and distance(s)to adjacent well(s)below and show on map: Note:during yield test of new well,adjacent public and private wells may need to be monitored per CGS Sec.25-33. 4.Provide a general description of the topography and terrain of the proposed well site: 5.Attach a scaled site or street/zoning map containing the following items: Location of proposed well(s) Adjacent public and private active/inactive well(s) Sanitary radius (75 feet,150 feet,or 200 feet)depending on desired well yieldLandownershipand/or easement boundary. Existing and potential sources of pollution (see table on next page)Topographic contours if available IOO—year flood elevation contour if available North arrowD‘e‘mreomp? 1.Is the proposed well site located above the 100-year flood elevation?()Yes ()NoIfno,describe What measures will be taken (flnal site grading,etc.)to ensure that the immediate area surrounding the well is located above the 100-year flood elevation or submit flnal site grading plan: SECTION C.SOURCES OF POLLUTION 1.Are there any known contaminated areas within 1,500 feet of the proposed well site?()Yes ()No If yes,describe them below and indicate separating distances.Note:the DEP Bureau of Waste Management should be contacted to obtain information on known areas of contamination. 2.Is groundwater flow from existing or potential sources of pollution away from the well site?()Yes ()No 2.If not applicable,enter NA.If multiple sources of same type of pollution source (i.e.multiple catch basins)enter distance to pollution source closest to proposed well site. 3.Separation distances may be required to be doubled based on soil percolation rate and depth to ledge rock per Section II of the Technical Standards for the Design and Construction of Subsurface Sewage Disposal Systems (Pursuant to RCSA Section 19-13-B103,revised 1/1/2000). 4.If sanitary sewer is constructed of extra heavy cast iron pipe with leaded joints or equal approved type ofjoint,a minimum separating distance of 25 feet is required per RCSA Section 19-13-B51d(a)(2). 5.If sanitary sewer is constructed of extra heavy cast iron pipe with leaded joints or equal approved type ofjoint,a minimum separating distance of 75 feet is required per RCSA Section 19-13-B51d(a)(2). 6.If sanitary sewer is constructed of extra heavy cast iron pipe with leaded joints or equal approved type ofjoint,a minimum separating distance of 100 feet is required per RCSA Section 19-13-B51d(a)(2). 7.Auto-analyzer waste or sample tap discharge only.All other discharges must meet 75,150,or 200 foot separation distance based on pumping rate. 8.Lakes,ponds,rivers,streams,wetlands,swamps,seasonal standing water,etc.If proposed well will be gravel packed and is located within 200 feet of a surface water body,a GWUDI study will be required. 9.Not applicable to liquid fuel storage tanks located in basements with concrete floors and no floor drains. 10.Not applicable to above ground storage tanks or piping containing a gaseous fuel. 11.Refer to RCSA Section 19-13-B5 1b,Definition #14. 3.Complete the following table: v i‘ Polliltion Source ’Rectuired Separation distances (feet)based on well pumping ratei Actual .. SeparationDistance (feet? ‘.‘<:10 ‘gpm ’10350.gpm ’ >50‘gpm Subsurface Sewage System (septic tank/leaching fields) 753 1503 2003 Sanitary Sewer 754 1505 2006 Storm Drain 25 50 50 Foundation,Floor Drain 25 50 50 Dry Well7 50 50 50 Annual High Water Mark for Surface Water Bodys 25 50 50 Liquid Fuel Storage Tank/Piping9 75 1 5 0 200 Gaseous Fuel Storage Tank/Piping“)75 150 200 l.Per RCSA Section 19-13-B51d. Certification Statement: I certify to the best of my knowledge that the information provided in this application is complete and correct.I understand that the information I provide will be used by the Department of Public Health,Drinking Water Division to determine if a Well Site Approval can be granted.I further understand that if an approval is issued,the well must be drilled in the location approved by the Department. Signature of Applicant Name of Applicant (print or type) Date Title (if applicable) This application along with additional information on the well site process can be located on the DPH Drinking Water Division’s web page:http://Www.dph.state.us/BRS/VVater/DWBhtm Departmental Use Only Existin Public Water Sstemgys Proj ect Number Initials Initials Initials Approved] Yes No Date ApprovedDateReceivedDateDateDateSent SWP Approval! Yes No Compl.Approvall Yes No Comments Initials 1 .Attach comments if necessary revised 3/9/04 S:\SWP UNIT\well siting\well site application 3 9 04 Date of Well Site Inspection: DPUC l6-262m Certificates of Convenience and Necessity Proj ects: Docket Number In1t1als Initlals Initials Initials Yes No Date Received Date Date Date Sent Date Date Approved Planning Approvall Yes No SWP Approval Yes No Comments Compl.Approvall Yes No Initials Page 1 0f2 DeVito,Robert From:Straut-Esden,Ann [Ann.Straut—Esden@ct.gov] Sent:Thursday,May 01,2008 2:15 PM To:DeVito,Robert Subject:TNC Info for New Well Attachments:GENERAL APPLICATIONDOC;Scr_App_|nstructionsDOC;Screening_App.DOC; Instruction;NC DOC;NC Phase i ADOC;well_site application pdf'pollution_sources pdf'FLooo.pdf_;NC_'Phase_I ‘A_Att_1"60c:-NC_Phase_I‘_A_Att_2.DoC;’NC_PHASE I_B.ooo; Wel|_Water_Quality_and:Quantity;Suitebility_Application.doc;general_terms.pdf;VIELD% 2OTEST%20LOG.pdf;NC_Phase_ll.DOC Creating a new public water system —the papenlvork looks intensive,but really isn’t.Everything is available on our website at:http://www.ct.gov/dph/cwp/view.asp?a=31 39&q=387304&dphNav_GID=1 824 The information for creating a new water system (and the forms)are here:hjtp;[/www:cttgovjidpj/cwp/view.aspj a=31 39&g=387326 This is usualiy a 3 "phase”process. Before the system does anything,they should send in a screening application.This is used to make a determination if they will be a public water system or not. Phase IA is the well site.For this phase,we’d need the CPCN Phase lA application,a well site application, Once an approval to drill the well site has been issued,the well would be yield tested and water quality samples would be taken.Which samples to take are spelled out on the Water Quality and Quantity Suitability Application form,which is available on the forms section of our website.For this phase,you would submit the Phase ii application,the Well Water Quality and Quantity Suitability Application,the yield test log,the water quality results, the well drilling permit,the well drilling completion report. A Water Quality and Quantity Review will be performed and,based on the yield test and water quality results,a phase ll is usually submitted.A phase ll can include things such as piping,well cap,casing extension,well pump, pump house,storage tanks,booster pumps and treatment.i don't believe this project will have all that,so,you would submit a Phase ll application and attach the pertinent information about the system such as a schematic of the system and the make/model of equipment being installed. From here,you’d get a project approval and put the finishing touches on the system.We’d come out and do an inspection and issue the certificate,a final approval and a well use. The General Application Form (GAF)is just our “cover letter"for all projects coming into the office.Submit one each time you submit a new phase that is not bundled with another one (you could do Phase lB and Phase ii together for instance and only need one GAF.This is also available on the forms section of our website. Seems complicated,but it’s not.Take each phase individually and it will go smoother and fairly quickly. l bet you’ll have more questions now © Questions about the general how to i can probably answer.Questions about the screening application need to go to Sara Ramsbottom (same 860-509-7333 #). ~Ann ****************************************** 5/2/2008 Ann A.Straut-Esden State of Connecticut -Department of Public Health Drinking Water Section Voice:860-509-7333 Fax:860—509-7359 ann.straut—esden@ct.gov http://Www.ct.g0V/dphf 5/2/2008 Page 2 of 2 DRINKING WATER SECTION SOURCES OF POLLUTION -FUELS Section 19-1 3-B51d of the Regulations of Connecticut State Agencies speils out separating distance requirements between a public water supply well and a “system for disposal of sewage or other sources of pollution"based on well withdrawal rates.For the purpose of this regulation,“other sources of pollution”includes but is not limited to the following: o Any above or below ground storage tank or piping containing a liquid fuel (e.g. gasoline,fuel oil,kerosene). The above clarification does not apply to: o Any above or below ground storage tanks or piping containing propane or natural gas.0 Any fuel storage tanks or piping located in basements with concrete floors and no floor drains. o Any fuel storage tanks or piping located within 200 feet of a public water supply well and used by the public water supply for standby power providing that additional precautions have been taken to protect the well. Note:although storage tanks containing propane or natural gas are not considered sources of pollution,it is recommended that such tanks be located at least 25 feet from a public water supply well for safety considerations. Revised:October 25,2006 DRINKING WATER SECTION WELL LOCATION RELATIVE TO HIGH WATER MARK AND 100 YEAR FLOOD LEVEL PURPOSE:This document is intended to clarify the requirements of Public Health Code (PHC)Section 19-13-B51d regarding the separating distance to the high water mark and Section 19-13-B102d relative to well location. FACTS:Section 19—13—B51d clearly requires that no well shall be located within 25 or 50 feet of the high water mark of any surface water body.Section 19-13-B32a defines the high water mark to mean the upper limit of any land area which water may cover, either standing or flowing,at any time during the year. Section 19—13-B102d requires that new water facilities,which include a water well, shall be located above the one hundred year elevation. CLARIFICATION:In light of the above,the Drinking Water Section has determined that the one-year flood level is the high water mark and as a result,any reference in the PHC to the high water mark shall mean the one—year flood level.The groundimmediatelysurroundingthewellshallbelocatedabovethe100yearfloodlevel with the well casing extended above ground pursuant to Section 19—13—B51f of the PHC and shall meet the required separating distance as specified in Section 19—13-BSld of the PHC. Effective Date:March 25,1992 Revised:August 12,1997 ag w t , 4m > m 4 ac q g my a2 . fa w “a .w w v mO x < k w 5 ¢z r r < ¢ m u w w 2: . “ >0 3 0 m ZO E Q O O . . . .j w > > \r e g c l a r \ f l o o d . d o c \s e c t i o n l \ s e c t s t a t S' Attachment 1 Non-Community CPCN Phase I-A Non—Community Phase I-A Certificate 0f Public Convenience and Necessity (CPCN) Average Daily Demand (ADD)Calculation Worksheet for Item #4 The average daily demand (ADD)in gallons per day (GPD)for a system shall be calculated based on “Design Flows” identified in Section IV of the most recent revision of the “Technical Standards for Subsurface Sewage Disposal Systems”. Documentation from the local building official for the town in which the project is to be constructed with regards to the use of building space may be necessary to determine the design flow.If demonstrated to and approved by the DPH,historic or available water use data for a specific facility times a safety factor of 1.5 may be used in lieu of calculated daily design flows. The most recent version of the Technical Standards referenced above is 1/1/2004,and are available by using this link: http://www.dph.statect.us/phc/subcode.pdf.Refer to page 27 for Section IV —Design Flows. The "#Persons”is the number of pupils,employees,camp spaces,beds,seats,etc.as indicated on the Design Flows table in the Technical Standards.Indicate which category used.If more than one category is used,calculate each category separately and sum. Is historic or other available water use data being used in lieu of calculated design flows (Y/N)?If yes,submit justification for the use of that data and use the following calculation: ADD:X 1.5 (factor of safety)= If using the referenced technical standards,use the following table for calculating the ADD. #Persons GPD per person (from Tech.Stds.)Total GPD Category: X Category: X Category: X Category: X Category: Total projected ADD = FOR DWS USE ONLY DWS Project it:DPUC Docket#: Review:Cl Satisfactory E insatisfactory Date of determination:Revised:11/2/05 Attachment 2 Non—Community CPCN Phase I—A Page 1 of 2 TECHNICAL,MANAGERIAL,&FINANCIAL (TMF)CAPACITY EVALUATION A11 new public water systems must develop and maintain adequate fmancial,managerial,and technical capacity to meet the requirements 0f state and federal regulations.The answers given to the following questions will be used to evaluate the knowledge and awareness of the property owner with the responsibility of owning a public water system. FOR DWS USE ONLY DWS Project #:'DPUC Docket#:Revised:12/6/05 General Questions (Managerial Capacity) 1.Do you have any experience with the ownership and/or operation of a business?D Yes D No If yes,describe. 2.Do you have previous experience with the ownership and/0r operation of a public water system?D Yes D No If yes,describe. 3.Are you familiar with the state and federal regulations regarding public water systems?D Yes D No Have you read these regulations?D Yes D No 4.Who will be responsible for management of the water system? Proposed Water System Information/Operation (Technical Capacity) 5.Is the proposed building site suitable for drinking water source development?D Yes B No 6.How will the drinking water source of supply sanitary radius be protected and adequate sanitary conditions maintained? 7.What local approvals are required (zoning,construction,etc)?Which,if any,have been obtained? 8.Have you contracted with a Professional Engineer or water system professional for the design of the proposed water system?D Yes D No If yes,who? 9.What classification of water system will the facility be?(C,NTNC,or TNC) 10.Will this proposed water system require a certified operator?D Yes D No ll.What are the water quality monitoring requirements for this public water system classification? Attachment 2 Non—Community CPCN Phase I-A Signature of Property Owner/Legal Contact: Date: Print name: FOR‘DWS USE ONLY DWS Project t}:DPUC Docket#: Evaluation Review:D Satisfactory E]Unsatisfactory Date of determination:Revised:12/6/05 Page 2 0f 2 12.Have you contacted a Connecticut-certified 1aboratory(ies)regarding water quality monitoring costs? D Yes D No What 1ab(s)and what is estimated cost? 13.What services are the lab(s)you contacted offering to provide?(This may include reporting to the DWS.) 14.Are you aware that future regulations may result in additional monitoring requirements for public water systems?B Yes B No 15.Are you aware that the water systern may need continuous water treatment,depending on results of water quality tests?B Yes B No Financial Capacity Information 16.How will construction of the water system be paid for?l7.Name of Lending Institution (if applicable) 18.What is the cost estimate for the proposed water system?19.If none,when will it be completed? 20.Are you aware of future costs associated with a public water system?B Yes D No 21.How will the annual costs be paid for? 22.Estimated Annual Monitoring Cost 23.Estimated Annual Operating Cost 24.Estimated Annual Maintenance Cost 25.How do you plan to handle emergency repair situations?26.How will emergency costs be paid for? 27.Do you plan to,or have you,set up a reserve fund for annual/emergency costs?E]Yes D No If so,what type(s)?(e.g.escrow) Non-Community CPCN Phase I-B (Page 1 of 1) STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH &DEPARTMENT OF PUBLIC UTILITY CONTROL APPLICATION FOR A NON-COMMUNITY CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (CPCN)Pursuant to CGS Sec.16-262m This application process is S€parated into three phases —Phase I-A,Phase I-B,&Phase II.Only complete one phase at atime.Do not move on to a subsequent phase until the Department of Public Health —Drinking Water Section hasformallyreviewedtheprecedingphaseandwrittenconfirmationhasbeenreceivedtocontinuetheprocess. PHASE I-B (Non-Community) DPH-DWS PROJECT #:(as assigned by this office) The following must be submitted for the Phase I-B Non-Community CPCN review,as required per Phase I-A approval (check off each that is included with this submission): D l.Copy of the DWS’s determination of the Phase I—A application B 2.Completed Well Water Quality and Quantity Suitability Application,which includes the following: E 2a.Copy of well drillers’completion report for each well drilled D 2b.Copy of yield test results for each well indicating pumping rates,certified well yields,and drawdowninformation D 2c.Copy of all water quality test results from samples obtained as required on the Well Site Suitability Certification D 3.Estimated itemized cost of water facilities to be constructed/expanded Signature of Property Owner/Legal Contact:Date: Signature of ESA provider (if applicable):Date: (If no ESA provider:signature of representative of regulated water company that is to own &operate the proposed water system,if applicable) FOR DWS USE ONLY DWS Project #:DPUC Docket#: Approved to proceed with Phase II:D Yes D No Date of determination:Revised:l lfl 0/05 DPUC DOCKET #:(as assigned by DPUC) Facility/PWS Name:PWSID:CT (if applicable) (Facility name as on the Phase I-A application) STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION WELL WATER QUALITY AND QUANTITY SUITABILITY APPLICATION Instructions Following the construction,water quality testing,and yield testing of a new public water system (PWS)water supply well,this application should be completed and submitted to the Department for review and determination of suitability of the well water quality and guantity (safe yield).Note that this application is step 2 of a four-step approval process which is required to be followed prior to active use of the new well.The other approval steps include step 1 (Well Site Suitability),step 3 (treatment,piping,etc.),and step 4 (Well Use Approval). Section A.r :Genera’l Information 1.PWS Name: PWSID #:CT Town: 2.Please provide the name of the primary contact person who can answer technical questions regarding this project: Name: Title: Company: Address: Phone Number: Fax Number: E-mail: 3.The following information,at a minimum,must be submitted with this application: a.Has a completed Public Water System General Application for Approval or D Yes D No Permit for this project been submitted? b.Has a copy of the Well Drilling Permit been submitted?D Yes D No c.Has a copy of the Well Drilling Completion Report been submitted?D Yes B No d.Has a copy of the Yield Test Log been submitted?B Yes D No e.Has a reference map identifying the location of the well been submitted? L D Yes D No ................................................................................................................................................. rev.4/11/07 STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION 4.Has any additional supporting information/documentation been submitted along B Yes D No with this appiication? Section B.Well Information 1.Well Name: 2.Type of Well (select one): E BedrockEGravel Packed D Other: 3.Primary Purpose of Well (select one): D Primary Source of Supply B Backup to Existing Source of SupplyDEmergencySourceofSupply U Other: 4.ls this well a replacement for an existing well?E Yes D No lf yes,indicate the name of the existing well that is being replaced by this well: 5.Site Location: Latitude/Longitude of Well: Latitude:O Longnude:O I ll 6.Date Well Site Suitability Certification Issued by Drinking Water Section: rev.5/14/07 2 of 12 W611 Water Qual./Quant.Suitability App. STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION 7.Well Construction Information (if not applicable,indicate N/A): Name of Licensed Well Driller: State of CT Well Drilling License #2 Date Wen Compietedi: Weli Depth (ft)2.. Well Casing Diameter (in): Well Casing Length (ft): Grout Depth (tt)2: Well Casing Material: Well Screen Type: Depth to Top of Screen (ft)2: Make and Model of Well Cap 3.. 1.Per Well Drilling Completion Report 2.Measured from ground surface level 3.Include manufacturer’s cut sheet What types of logs are available for this well?(select all that apply) E Acoustic D Caliper D Drillers B Electrical D Geologist B Radioactive D Temperature B Video Installed Well Pump Information:(pump information may be submitted later if not available) Pump Type (select one): E Submersible B Vertical TurbineBJet B Other: Make and Model1: Pump Capacity (gpm)1: Motor Size (hp): Depth to Wen Pump (tt)2: 1.Include manufacturer’s pump curve 2.Measured from ground surface level rev.5/14/07 3 of 12 Well Water Qua1./Quant.Suitability App. STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION 9a.Will there be any treatment for this well?DYes B No Section C.Yield Test 1-Date(s)of Yield Test: Duration of Yield Test (hours): Yield Test Performed By: Static Water Level Depth (ft)’: Static Water Level Observation Date: Stabilized Drawdown Depth (ft): Duration of Stabilized Drawdown (hours): Stabilized Pumping Rate (gpm): Safe Yield in gpmz: Safe Yield in gpd3: 1.Measured from ground surface level 2.For bedrock wells =stabilized pumping rate X 0.9 For gravel packed wells =stabilized pumping rate 3.Safe yield in gpd =safe yield in gpm X 18 X 60 rev.5/14/07 4of12 Well Water Qual./Quant.Suitability App. 9b.If yes,describe what type of treatment is proposed and why treatment is proposed to be installed: rev.5/14/07 5 of 12 Well Water Qua1./Quant.Suitability App. STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTHDRINKINGWATERSECTIONSectionD.Water Quality The following table outlines the water quality testing that must be conducted depending on the type system for which this well was drilled.Please refer to RCSA Section 19-13-B102(a)“Definitions”if further clarification with respect to system type is needed. of Public Water System Type:Required Monitoring: Community (C)Tables A through H1 Non-Transient Non-Community (NTNC)Tables A through E,G and H1 Transient Non-Community (TNC)Lables A,B,C (only nitrate and nitrite),D,G and 1. 1. lt Table H is only applicable to gravel packed wells that will be subject to a determination for Groundwater UnderDirectInfluenceofSurfaceWater is recommended that testing for the parameters identified in Table l also be conducted.Additionally,NTNC and TNC systems should test for all parameter categories outlined in this document. When to Monitor:A well must be chlorinated during or immediately upon completion of its construction. Water quality samples shall be collected just prior to the completion of a yield test.Under this scenario the water produced from a well and ground water bearing structure would be in a flushed condition and should have no remaining chlorine.lt is important to have coordination with laboratory staff or State certified operator that will be conducting this sampling. The following tables identify the standards,maximum contaminant levels (MCL),U.S.Environmental Protection Agency secondary maximum contaminant levels (SMCL),DPH guidance/action level list January 2003 and March 2004 (AL)applicable for each parameter.Additional abbreviations used in this document: mg/L —milligram per liter;pg/L —microgram per liter;pCi/L —picoCurie per liter;mrem —millirem (remRoentgenEquivalentMan);MDL —method detection limit;NTU —Nephelometric Turbidity Unit;MFL million fibers per liter;mL —milliliter. The results of the required water quality monitoring as identified above must be entered into the applicable Results columns in the following tables.in addition,the name and certification number the state certified laboratory which conducted the testing must be entered for each table.If any parameters were subcontracted,the name(s)and certification number(s)of the subcontracted laboratories must also be listed where applicable. Table A —Bacteriological — — of Laboratory Name: Lab lD#:PH-Sample Collection Date: Parameter:Standardi *Results: Total Coliform Absent /Zero (0) Fecal Coliform or Ecolit Absent /Zero (0) Total chlorinez Zero (0)1.Fecal Coliform or Ecoli are required to be analyzed if result for the total collform is present/positive.2.This is conducted in the field to verify that there is no chlorine present in the water that would invalidate abacteriologicalsample. rev.5/14/07 60f12 Well Water Qual./Quant.Suitability App. 2. STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION Table B —Physical Parameters Laboratory Name: Lab !D#:PH-Sample Collection Date: Parameter:Standard:Results: pH 6.4 —10.0 Color 15 color units Turbidity 5 NTU Odor 2 3.Table C —Inorganic Chemicais (IOCs) Laboratory Name: Lab iD#:PH-Sample Coiiection Date: Were any parameters subcontracted to another lab?D Yes D No If yes,indicate the name and iD#of the subcontracted Iab(s)and inciude the subcontracted Iab iD#with the sample result in the results column for those parameters that were subcontracted. Subcontracted Lab(s): Subcontracted Lab ID #:PH- .fParameter:'ti:»,MCL or as notedtmg/L):Results (mg/L): Antimony 0.006 Arsenic 0.01 Barium 2 Beryllium 0.004 Cadmium 0.005 Chromium 0.1 Cyanide 0.2 Fluoride 4.0 Mercury 0.002 Nickel 0.1 Nitrate 10 Nitrite 1 Selenium 0.05 Silver 0.05 Sulfate 250 [SMCL] Chloride 250 Thallium 0.002 Lead 0.015 [AL] Copper 1.0 [SMCL] Sodium 28 [notification level] rev.5/14/07 7of12 Well Water Qua1./Quant.Suitability App. 4. STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTHDRINKINGWATERSECTION Table D —Volatile Organic Chemicals (VOCs) Laboratory Name: Lab lD#:PH-Sample Collection Date: Were any parameters subcontracted to another lab?E Yes D No If yes,indicate the name and ID#of the subcontracted Iab(s)and include the subcontracted lab ID#with the sample result in the results column for those parameters that were subcontracted. Subcontracted Lab(s): Subcontracted Lab ID #:PH- Paramete‘‘r:.MCL or as noted:(mg/L):Results (mg/L): Benzene 0.005 Bromobenzene Bromomethane n-Butyl Benzene Carbon Tetrachloride 0.005 Chlorobenzene 0.1 Chloroethane Chloromethane 0.055 [AL] o-Chloroto uene p-Chloroto uene Dibromomethane m-Dichlorobenzene 0.21 [ALI o-Dichlorobenzene 0.6 p—Dichlorobenzene 0.075 1,1-Dichloroethane 0.08 [AL] 1,2-Dichloroethane (EDC)0.005 1,1-Dichloroethylene 0.007 cis-1,2-Dichloroethylene 0.07 Trans-1,2-Dichloroethylene 0.1 Dichloromethane (Methylenechloride)0.005 1,2-Dichloropropane 0.005 1,3-Dichloropropane 2,2-DiChloropropane 1,1-DiChloropropene 1,3-Dichloropropene Ethylbenzene 0.7 Methyl Tert Butyl Ether (MTBE)0.07 [AL] Naphthalene 0.0065 [AL] n-Propyl Benzene Styrene 0.1 1,1,1,2—Tetrachloroethane 0.021 [AL] Table D is continued on next page... rev.5/14/07 8of12 Well Water Qual./Quant.Suitability App. STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION Table D (VOCs)continued Parameter:MCL or as noted (mg/L):Results (mg/L): 1,1,2,2-Tetrachloroethane 0.028 [AL] Tetrachloroethylene 0.005 Toluene 1 Total Trihalomethanes (TTHM)0.080 Bromodichloromethane Bromoform Chlorodibromomethane Chloroform 1,1,1-Trichloroethane 0.2 1,1,2-Trichloroethane 0.005 1,2,4-Trichlorobenzene 0.07 Trichloroethylene 0.005 1,2,3-TriChloropropane 0.00005 [AL] 1,2,4-Trimethylbenzene 0.036 [AL] 1,3,5-Trimethylbenzene 0.036 [AL] Vinyl Chloride 0.002 Xylenes (total)10 m-Xylene o-Xylene p-Xylene*MCL or AL has not been established for this Chemical.**The MCL for Total Trihalomethanes (TTHM)is the sum of these four (4)constituent Trihaiomethanes.***The MCL for Xylenes (total)is the sum of these three (3)constituent Xylenes. rev.5/14/07 Well Water Qua1./Quant.Suitability App.9of12 5. STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Table E —Synthetic Organic Chemicals (SOCs) Laboratory Name: Lab lD#:PH-Sample Collection Date: Were any parameters subcontracted to another lab?B Yes D No If yes,indicate the name and lD#of the subcontracted Iab(s)and include the subcontracted Iab lD#with the sample result in the results column for those parameters that were subcontracted. Subcontracted Lab(s): Subcontracted Lab ID #:PH- Parameter:l‘MCL or as noted (mg/L):a Results (mg/L): Alachlor 0.002 Aldicarb Aldicarb sulfoxide Aldicarb sulfone Aldrin Atrazine 0.003 Benzo(A)pyrene 0.0002 Butachlor Carbaryl Carbofuran 0.04 Chlordane 0.002 Dalapon 0.2 Di(2-ethylhexyl)adipate 0.4 Di(2-ethylhexyl)phthalates 0.006 Dicamba Dieldrin 0.00003 [AL] Dinoseb 0.007 Diquat 0.02 Dibromochloropropane (DBCP)0.0002 2,4-D 0.07 Ethylene dibromide (EDB)0.00005 Endrin 0.002 Endothaw 0.1 Glyphosate 0.7 Heptachlor 0.0004 Heptachlor epoxide 0.0002 Hexachlorobenzene 0.001 Hexachlorocyclopentadiene 0.05 3-Hydroxycarbofuran Lindane 0.0002 Methoxychlor 0.04 Table E is continued on next page... rev.5/14/07 10 of 12 Well Water Qua1./Quant.Suitability App. F STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH DRINKING WATER SECTION Table E (SOCs)continued Methomyl Metolachlor Metribuzin Oxamyl (vydate)0.2 Picloram 0.5 Propachlor Simazine 0.004 2,3,7,8—TCDD (dioxin?0.00000003 Polychlorinated biphenyls (PCB)0.0005 Pentachlorophenol 0.001 Toxaphene 0.003 2,4,5-TP (silvex)0.05 6. MCL or AL has not been established for this chemical. 1.The DPH may grant a waiver from monitoring for endothali if it is demonstrated that within the past year treatment with endothail has not been appiied to any body of water,turf on sod farms or golf courses within the watershed or zone of influence of the source of supply.[Section 19-1 3-B1 02(e)(7)(C)(xiii)of the PHC] 2.The DPH may grant a waiver from monitoring for dioxin if it is demonstrated that the watershed or zone of influence has not been or is not being used for any of the following land uses:pesticides and herbicides manufacturer,pulp and paper manufacturer,plastics manufacturer,wood preservative manufacturer,landfill and domestic waste transfer station,or hazardous waste disposal facility.[Section 19-1 3—B102(e)(7)(C)(xii)of the PHC] Note:See definition for “zone of influence”under Sec.19—1 3-B102(a)(97)of the PHC. Table F —Radionuclides Laboratory Name: Lab lD#:PH-Sample Collection Date: Were any parameters subcontracted to another lab?D Yes B No If yes,indicate the name and lD#of the subcontracted Iab(s)and include the subcontracted lab lD#with the sample result in the results column for those parameters that were subcontracted. Subcontracted Lab(s): Subcontracted Lab ID #:PH- Parameteré‘i‘2i .9?*~.MCL:ii ,Results:‘. Gross Alpha1 15 pCi/L Radium-226 5 poi/L <2) Radium-228 5 poi/U2) Uranium 30 pg/L (ug/L=1 .49 X pCi/L) Beta Particle &Photon Emitters3 4 mrem/yr 1.includes radium-226,excludes radon and uranium activities 2.MCL for combined radium-226 and radium-228 equals 5 pCi/L3.Only required of community water systems with proposed source deemed “vulnerable”.PWS must test for Gross Beta,Tritium,and Strontium-90. rev.5/14/07 11 of12 Well Water Qual./Quant.Suitability App. 7. STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTHDRINKINGWATERSECTION Table G -Sanitary Chemicals Laboratory Name: Lab lD#:PH-Sample Collection Date: Parameter:Standard:Results: Iron 0.3 mg/L [SMCL] Manganese 0.05 mg/L [SMCL] Hardness Alkalinity * 8. *MCL or AL has not been established for this chemical. Table H -Microscopic Particulate Analysis (MPA) Laboratory Name: Lab lD#:PH-Sample Collection Date: Were any parameters subcontracted to another lab?B Yes D No If yes,indicate the name and lD#of the subcontracted Iab(s)and include the subcontracted Iab lD#with the sample result in the results column for those parameters that were subcontracted. Subcontracted Lab(s): Subcontracted Lab ID #:PH- Parameter:I R’ela’tive‘Risk Factorsgilow;I '’ moderate or high ;4 “Regurts;i Biological indicators of surface watera high 9. a.Giardia,Cryptosporidium,Coccidia,Diatoms.Algae,Insects/Larvae,Rotifers and Plant Debris Table I -Miscellaneous Parameters Laboratory Name: Lab lD#:PH—Sample Collection Date: Were any parameters subcontracted to another lab?B Yes E No If yes,indicate the name and lD#of the subcontracted Iab(s)and include the subcontracted lab lD#with the sample result in the results column for those parameters that were subcontracted. Subcontracted Lab(s): Subcontracted Lab ID #:PH- Parameter:’I I I Recommended standards as' noted:Results: Heterotrophic Plate Count (HPC)<500/mL Iron Bacteria Absent/Zero (O) Drinking Water Section Use Only DWD staff who conducted technical review: Date technical review completed: Water quality and quantity for this well is:E Approved U Rejected Comments: rev.5/14/07 12 of 12 Well Water Qual./Quant.Suitability App. STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTHDRINKINGWATERSECTION[Section E.Certification This application must be signed by the PWS administrative official,his/her authorized representative,or certified operator of the PWS. I hereby certify that i have examined the information contained in this appiication as submitted to the Department and found it to be accurate to the best of my knowledge: Signature:Date Signed: Name (Print):Telephone #2 Title and Relationship to PWS: DEPARTMENT OF PUBLIC HEALTH-DRINKING WATER DIVISION GENERAL TERMS FOR WELL SITE DEVELOPMENT Prior to this office issuing an approval for use,any well that will increase the water system’s potential maximum withdrawal rate to a level in excess of 50,000 gallons during any 24- hour period,or is part of a system that already exceeds this withdrawal rate,may require a groundwater diversion permit from the State of Connecticut Department of Environmental Protection (DEP).The well owner should contact the DEP permit division regarding this requirement.New wells replacing failed wells already registered with the DEP may be exempt.A well use approval will not be issued without the necessary DEP permits. Prior to this office issuing an approval for use,a well yield test must be performed in accordance with the appropriate duration specified below: Note:For all wells,test pumping shall be continuous at a constant rate for the period required and drawdown shall have held essentially stable for the last 12-hours prior to the completion of the test.All existing and new wells will be pumped and measured simultaneously.See Section 19- l3-B51k (b)of the Regulations of Connecticut State Agencies (RCSA)for additional details. Immediately upon completion of drilling the well casing must be sealed in a sanitary manner to protect the well from the entrance of surface water and foreign matter.Immediately upon installation of the submersible pump the well must be equipped with a certified watertight well cap,per Section 19—13-B5 1j(a)of the RCSA. Water quality tests must be performed in accordance with the attached document entitled“WATER QUALITY MONITORING OF PROPOSED/NEW SOURCES”.The results of these tests must be submitted to our office for approval. Upon well completion this office must receive copies of the following documents for review and approval: Water Supply Well Permit Well Completion Report Yield Test Log (attached) Specifications for Submersible Well Pump (model,depth setting,pumping capacity) Specifications for the Certified Watertight Vented Well Cap Water quality analyses Any pertinent hydrogeologic data Plans for the piping arrangement to connect the new well and for proposed treatment (if any) must be reviewed and approved by the Drinking Water Division prior to installation. Upon installation and prior to making the well water available for use,this office must conduct an inspection to review the well construction,piping arrangement and treatment equipment.The inspection must be completed prior to issuing a Well Use Approval in accordance with Section l9-l3-B5 11 of the RCSA. ‘eappwo Anticipated Withdrawal Rate of Well (gpm) Duration of Yield Test Less Than 10 18 hours 10 to 50 36 hours Greater Than 50 72 hours YIELD TEsT LOG Nam6 of Utility: Source Designation: Person Conducting Test:Firm: Address of Firm: 8.All groundwater sources must be pump tested to determine the yield 9.The pump must run continuously during the yield test.Please refer to Step 7 of the Well Site Approval for details on well yield test requirements. 10.Pump rate and drawdown must be stable for at least the last 12 hours of the yield test (excludingminorpumpingrateadjustmentsofbriefduration). ll.The pump test will be used to determine the safe yield of the well.The withdrawal rate may be limited due to restrictions cited in the well site approval.The maximum pumping capacity of the well will be 90%of the rate determined by the yield test. 12.The following items must be measured during the test: a,Depth to which pump is set (measured from the top of the casing). b.Static water level before pumping (measured from the top of the casing). c.Time,pump rate,and drawdown (at least hourly). d.Time and water levels after pump has been shut down until well has recovered. 13.A table has been provided for use as the yield test log. Connecticut Department of Public Health Drinking Water Division 410 Capitol Avenue —MS#5 l WAT P.O.Box 340308 Hartford,CT 06134 (860)509-7333 http ://www.dph.state.ct.usfBRS/Water/DWD.htm Keeping Commute“:Healthy Name of Utility: Source Designation: Depth to pump: Static Water level: YIELD TEST LOG ft. ft. 2 Water level minus static level.1 Measured from the top of the casing. Date Time Elapsed Time (Hrs.;Min.) Pumping Rate (gpm) Water Levell (feet) Drawdownz (feet)Comments YIELD TEST LOG Name of Utility: Source Designation: Person Conducting Test:Firm: Address of Firm: 8.All groundwater sources must be pump tested to determine the yield 9.The pump must run continuously during the yield test.Please refer to Step 7 of the Well Site Approval for details on well yield test requirements. 10.Pump rate and drawdown must be stable for at least the last 12 hours of the yield test (excludingminorpumpingrateadjustmentsofbriefduration). 11.The pump test will be used to determine the safe yield of the well.The withdrawal rate may be limited due to restrictions cited in the well site approval.The maximum pumping capacity of the well will be 90%of the rate determined by the yield test, l2.The following items must be measured during the test: a.Depth to which pump is set (measured from the top of the casing). b.Static water level before pumping (measured from the top of the casing). c.Time,pump rate,and drawdown (at least hourly). d.Time and water levels after pump has been shut down until well has recovered. 13.A table has been provided for use as the yield test log. Connecticut Department of Public Health Drinking Water Division 410 Capitol Avenue —MS#51WAT P.O.Box 340308 Hartford,CT 06134 (860)509-7333 http ://www.dph.state.ct.us/BRS/Water/DWD.htm keying Connecttea:Realms; Name of Utility: Source Designation: Depth to pump: Static Water level: YIELD TEST LOG ft. ft. 2 Water level minus static level.1 Measured from the top of the casing. Elapsed Water Time Pumping Levell Drawdownz Date Time (Hrs.;Min.)Rate (gpm)(feet)(feet)Comments