PWS NAME AND ID#: _________________________________________________________________ CHANGES IN WATER SOURCES* Date to be Online, Surface Water or Type of Water Name of Water Add or Remove Inactivated, or Ground Water Source Source Abandoned Contact Type Definitions Surface Sources stream, river, reservoir, lake, pond, etc. – Ground Water Sources well, spring, infiltration gallery, etc. – Date to be Online date the source became or will become active. – Date to be Inactivated the last day this water source will be used for drinking water. – Date to be abandoned date the source will be backfilled with bentonite mud, concrete, dirt, etc. – Please briefly describe the method of abandonment:
PWS NAME AND ID#: _________________________________________________________________ CHANGES IN WATER SOURCES* Add or Remove Surface Water or Ground Water Type of Water Source Name of Water Source Date to be Online, Inactivated, or Abandoned Contact Type Definitions Surface Sources – stream, river, reservoir, lake, pond, etc. Ground Water Sources – well, spring, infiltration gallery, etc. Date to be Online – date the source became or will become active. Date to be Inactivated – the last day this water source will be used for drinking water. Date to be abandoned – date the source will be backfilled with bentonite mud, concrete, dirt, etc. Please briefly describe the method of abandonment:
wy_change_form.docx