SITE INFORMATION AND CORRESPONDENCE

Home Browse Search

In n Shallow Injection ell SITE CHARACTERIZATION FORM, UIC Page 2 of 2 F7. Thisjection well receives (check all that apply) wastewater drained from shop area/maintenance bay wastewater drained from unroofed washing or rhaintenance facilities stormwater drained from facility ---_ sanitary wastewater drained from facility kitche s/bathrooms 8. What is the average rainfall per year in your area? _____ inches/year 9. How deep is the water table in your area? feet below ground surface If there is more than 5 foot fluctuation between wet and dry eason water table depths, please answer with I range. 10. Are there any public or private water supply wells within V2 mile of the injection well? __, yes ___ no Are there any wells at your site? __ yes ___ no 11. Is your injection well located in an area which has been designated by a state or local water supply agency as being vulnerable to contamination (such as Source Wate Protection Area, Wellhead Protection Area)? --- yes ___ no 12. Is your injection well located within 114 mile of any surface streams, public drainage ditches, or other waterways? ___yes ___ no 13. On a separate sheet of paper, please list all of the chemical products used at your facility(including soaps and other cleaning agents) which are in the drained area and are disposed of into the injection well or could, through contact with water or from a spill, drain to the injectic n well. If you have completed a similar list for your local hazardous materials program, a copy of that record should provide most or all of the information we are requesting. Please note presence of fuel. 14. Please attach 3 facility maps: a. Vicinity map, depicting site location relative to landma s within 1 mile radius, including waterways, streets/highways, and urban/industrial/residential areas, with orth clearly marked. b. Plan View map showing address, buildings at site,water wells, disposal wells, monitoring wells, and other distinguishable facility characteristics, with North clearly marked. c. Injection Well schematic: for each injection well, scaled arid detailed cross-section drawing of the shallow injection well, including the layout of all pipe and other const ucted conveyances, and other subsurface site features, such as underground storage tanks. 15. Does your shop use any Best Management Practices(B Ps)to physically isolate, minimize or eliminate use of potential contaminants? On a separate sheet of paper, please describe steps you have taken to limit use of drainage well to non-hazardous wastewater. HECK ALL ATTACHMENTS: • Inventory Form By signing this document, you are certifying that the . Site Use History information provided is true and correct to your . List of on-site contaminants knowledge as of this date: • 3 site maps: area, plan view, injection well list of BMPs to protect drains) Name (printed) or Regulator.Use Only ate Rec d.: w ---- — elect One.. =Rule autho Name (signature) by: nze M Sampling needed .onward to Y— Awn- Date = ;