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                                         Table 3.6  Example of Sanitary and Field Survey Report for Hydrogeologic Assessment
                                         Well Location and Characteristics
                                         Water System Name/Address/Fed ID#  ________________________________________________
                                                                       ________________________________________________
                                                                       ________________________________________________
                                         Name of Site _____________________________________________________________________
                                         Description of Device ______________________________________________________________
                                         Name and Description of Nearby Surface Source(s) _______________________________________
                                         ________________________________________________________________________________
                                         ________________________________________________________________________________
                                         Describe Datum for Elevations _______________________________________________________
                                         Is there a USGS gauging station nearby, or are other flow records available?
                                         ______________________
                                         Static Water Level
                                                 as a Depth ________________ Date ________________
                                                 as an Elevation ____________ Date ________________
                                         Pumping Water Level
                                                 as a Depth ________________ Date ________________
                                                 as an Elevation ____________ Date ________________
                                         Characterize pumping practices or spring flow (rates, seasonally, etc.)
                                         ________________________________________________________________________________
                                         ________________________________________________________________________________
                                         Describe the vertical distance between the aquifer and the surface-water under pumping conditions
                                         ________________________________________________________________________________
                                         ________________________________________________________________________________
                                         Describe the horizontal distance between the aquifer and the surface-water source under pumping
                                         conditions _______________________________________________________________________
                                         ________________________________________________________________________________
                                         Well Construction
                                         Construction date __________________
                                         Does construction conform to the current standards (i.e., Ten State)? _________________________
                                         Construction methods/materials ______________________________________________________
                                         ________________________________________________________________________________
                                                 Casing _________________________________________________________________
                                                 Grouting _________________________________________________________________
                                                 Screening ________________________________________________________________
                                                 Well House _______________________________________________________________
                                                 Other Information _________________________________________________________
                                         Is a detailed plan/drawing available? __________
                                         Hydrogeology
                                         Is a geologic log for this well available? ____________________________________
                                         What is the thickness of the unsaturated zone? _______________________________
                                         What is the hydraulic conductivity of the unsaturated zone and the aquifer? ______
                                         Is there a confining layer? At what elevation(s)? _____________________________
                                         Describe ____________________________________________________________
                                         Does the surface-water body penetrate the aquifer? ___________________________
                                         Draw the aquifer(s), confining unit(s), and water table using one or more cross-sections with at
                                         least one cross-sections parallel to the flow direction ___________________
                                         Summary of Sanitary Conditions
                                         Describe the results of past sanitary surveys and give the location of written reports
                                         ________________________________________________________________________________
                                         ________________________________________________________________________________
                                         ________________________________________________________________________________


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