Indiana Farmstead Assessment for Drinking Water Protection Drinking Water Well

Use this survey to assess the risk to groundwater quality posed by the condition of your drinking water well. At the end of each section sum the numbers that correspond to each answer for the section total. When you have completed the survey sum the section totals for the risk assessment score. Refer to for more information on your drinking water well.

For each question, a (1) represents a higher risk to drinking water than a (3).

Location & Site Characteristics

1. What is the texture of the soil around your well?

	clay  (3) 
	loam  (2) 
	sand  (1)

2. At the well site, is the water table or bedrock less than 20 feet
from the ground surface?

	Yes  (1)
	No   (3)

3. Is there a depression or sign of soil settlement near or around
your well?

	Yes  (1)
	No   (3)

4. Does surface runoff ever reach your well?

	frequently   (1) 
	occasionally (2)
	never        (3)

5. Is the water well upslope from all potential pollution sources?

	Yes; all  (3)
	No        (1)

6. What is the separation distance between the water well and each of
the following? Skip items not present on your farm.

a. sewer/drain inlet 	less than 15 feet  (1) 	greater than 15 feet  (3) 
b. septic tank 		less than 50 feet  (1) 	greater than 50 feet  (3) 
c. outdoor privies 	less than 50 feet  (1) 	greater than 50 feet  (3) 
d. absorption field 	less than 100 feet (1) 	greater than 100 feet (3) 
e. manure pit 		less than 50 feet  (1) 	greater than 50 feet  (3)
f. nearest stream, lake,
   pond, or ditch 	less than 25 feet  (1) 	greater than 25 feet  (3) 
g. nearest property line less than 15 feet (1) 	greater than 15 feet  (3) 
h. nearest dwelling 	less than 5 feet   (1) 	greater than 5 feet   (3) 
i. chemical storage 	less than 100 feet (1) 	greater than 100 feet (3)

Location & Site Characteristics section total _______________

Construction & Condition

7. How was your well constructed?

	dug or bucket (1)
	driven        (2)
	drilled       (3) 

8. How old is your well?

	less than 20 years old      (3) 
	between 20 to 70 years old  (2)
	more than 70 years old      (1)

9. How deep is your well?

	greater than 100 feet (3)
	25 to 100 feet        (2)
	 less than 25 feet    (1)

10. Does the well have a casing?

	Yes            (3) 
	No or not sure (1)

11. Does the casing extend the full depth of the well?

	Yes            (3) 
	No or not sure (1)

12. Are there any holes or tears in the casing?

	Yes (1)
	No (3)

13. How far does the well casing extend above the ground surface?

	below grade (in pit or basement) (1)
	between 0 to 11 inches           (2)
	12 inches or more                (3)

14. Are there any cracks or holes in your well cap?

	Yes, or well cap is missing (1)
	No                          (3)

15. Describe the fit of the well cap.

	tight  (3) 
	loose  (1)

16. Does the well have a vent?

	Yes, with screen (3)
	Yes, no screen   (2)
	No vent          (1)

Construction & Condition section total ____________

Maintenance & Testing

17. Are there any cross connections between your water supply line and potential sources of contaminated water?

	Yes  (1)
	No   (3)

18. How many faucet and hose connections have anti-backflow devices?

	none  (1)
	some  (2)
	all   (3)

19. Are there any unused or abandoned wells on your property that have
not been capped or plugged using a procedure approved by the Indiana
Department of Natural Resources?

	Yes       (1) 
	Uncertain (2)
	No        (3)

20. Do you have your water tested on a regular basis?

	annually     (3) 
	occasionally (2)
	never        (1)

21. Does your water meet state and federal quality standards?

	always               (3) 
	usually              (2) 
	seldom, or not sure  (1)

22. Does one or more of the following indicators of your drinking
water quality change during wet periods or following a storm: color,
clarity, odor or taste?

	Yes  (1)
	No   (3)

Maintenance & Testing section total ___________

Risk Assessment for Drinking Water Well

Add the following totals:

	Location & Site Characteristics section total ______ x 3 =   ________ 

	Construction & Condition section total _____ x 2 =           ________ 

	Maintenance & Testing section total =                        ________



Survey 1 Score  __________


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	Low	       	    Moderate			High
     270 - 150		    149 - 100		       99 - 30
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Click here for fact sheet 1

Drinking Water Well Fact Sheet