This Survey assesses the risk to groundwater quality posed by the condition of your drinking water well on the basis of the answers to the survey questions. Please answer all questions for a fair evaluation.

Location and Site Characteristics:

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

Clay
Loam
Sand
Corresponding magnitude of risk
 

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

Yes
No
Corresponding magnitude of risk
 

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

Yes
No
Corresponding magnitude of risk
 

4. Does surface runoff ever reach your well?  

Frequently
Occasionally
Never
Corresponding magnitude of risk
 

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

Yes; all
No
Corresponding magnitude of risk
 

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
Greater than 15 feet
Corresponding magnitude of risk
 

b) Septic tank:  

Less than 50 feet
Greater than 50 feet
Corresponding magnitude of risk
 

c) Outdoor privies  

Less than 50 feet
Greater than 50 feet
Corresponding magnitude of risk
 
d) Absorption field  
Less than 100 feet
Greater than 100 feet
Corresponding magnitude of risk
 

e) Manure pit:  

Less than 50 feet
Greater than 50 feet
Corresponding magnitude of risk
 

f) Nearest stream, lake, pond or ditch:  

Less than 25 feet
Greater than 25 feet
Corresponding magnitude of risk
 

g) Nearest property line:  

Less than 25 feet
Greater than 25 feet
Corresponding magnitude of risk
 

h) Nearest storage:  

Less than 5 feet
Greater than 5 feet
Corresponding magnitude of risk
 

i) Chemical storage  

Less than 100 feet
Greater than 100 feet
Corresponding magnitude of risk
 

Construction and Condition:

7. How was your well constructed?  

Dug or Bucket
Driven
Drilled
Corresponding magnitude of risk
 

8. How old is your well?  

Less than 20 years old
Between 20 years and 70 years old
More than 70 years old
Corresponding magnitude of risk
 

9. How deep is your well?  

Greater than 100 feet
25 to 100 feet
Less than 25 feet
Corresponding magnitude of risk
 

10. Does the well have a casing?  

Yes
No
Corresponding magnitude of risk
 

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

Yes
No or not sure
Corresponding magnitude of risk
 

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

Yes
No
Corresponding magnitude of risk
 

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

Below grade (in pit or basement)
Between 0 to 11 inches
12 inches or more
Corresponding magnitude of risk
 

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

Yes/ well cap is missing
No
Corresponding magnitude of risk
 

15.Describe the fit of the well cap.  

Tight
Loose
Corresponding magnitude of risk
 

16. Does the well have a vent?  

Yes, with screen
Yes, no screen
No vent
Corresponding magnitude of risk
 

Maintenance and Testing:

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

Yes
No
Corresponding magnitude of risk
 

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

None
Some
All
Corresponding magnitude of risk
 

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
Uncertain
No
Corresponding magnitude of risk
 

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

Annually
Occasionally
Never
Corresponding magnitude of risk
 

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

Always
Usually
Seldom, or not sure
Corresponding magnitude of risk
 

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
No
Corresponding magnitude of risk
 

Net Survey Score:
Magnitude of risk:

Return to Main Menu