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Drinking Water Source Assessment and Protection (DWSAP) Program <br /> Checklist for Drinking Water Source Assessment - Ground Water Source <br /> ��Transient Noncommunity Water System <br /> Public water system: �1C� itl� (�` Q-,CZA I I ID No.: <br /> Name of source: U-3EID No.: <br /> Assessment date: Assessment conducted by <br /> Water System Contact Name: QT-1 M )i i Phone#: 2LO 4t , <br /> Water System Contact Address: F)00 32&.,V 0 t°c <br /> The following information should be contained in the drinking water source assessment submittal. <br /> Checklist (this form) <br /> Delineation of groundwater protection zones <br /> Source Data Sheet(select appropriate form) <br /> Well Data Sheet(included) <br /> Spring Data Sheet(obtain from DHS or County office or DHS website) <br /> Horizontal Well Data Sheet (obtain from DHS or County office or DHS website) <br /> Possible Contaminating Activities (PCA) inventory form <br /> Assessment map with source location and protection zone <br /> Means of Public Availability of Report (indicate those that will be used) <br /> Copy in regulatory agency(DHS or LPA) office (minimum) <br /> Posted at public water system (recommended) <br /> Other(describe) <br /> Submit the specified forms to the DHS district office or LPA county office. Office staff will complete the <br /> assessment. <br /> Transient GW forms 2-2003.doc <br />