~¥7086 1950350004 Morceon) Werk sun.oinss a BETTER woRLD Cota me petis February 18, 2011 SE/fFecd Mr, Andrew Frierdich Project Manager Remedial Project Management Section Bureau of Land inois Environmental Protection Agency 1€21 North Grand Avenue East Springfield, IL 62702 Re: Work Plan GE Morrison Facility, Morrison, Hinois Consent Order No. 04 CH 28 0 R } 6) Ny : IGINA Dear. rich NAL Please find enclosed three copies of the Work Plan for the General Electric (GE) Morrison Fecility located in Morrison, Illinois. This report was prepared by MV/H Americas, Inc. (WH) on behalf of GE Energy. This report was prepared pursuant to the provisions of Consent Order No, 04 CH 28, Please call Mr. Andrew Graham (GE Energy) at 518-385-3423 or mysef at 312-831-3432 wih any questions or comments Sincerely, MWH AMERICAS, INC. RECEIVED Jus Pelee £822 20H Projet Manger IEPABOL Enclosures: Work Plan Consent Order 04 CH 28 cc: Paul Jagiello, lilinois Environmental Protection Agency (1 hard copy) Gerald T. Karr, Office of Attorney General (1 hard copy) Edward F. Jamison, GE Energy (1 electronic copy) Andrew Graham, GE Energy (2 hard copies, 1 electronic copy) H. Carl Horneman, Wyatt, Tarrant & Combs LLP (1 electronic copy) Timothy J. Harrington, Hard Hat Services (1 electronic copy) RELI opr 0 10800-101069911010616 GE Monison'4.0 Execution (Project Dalivernbies) 4.2 Work Plan\Morison_ Transmit Jetler_ Work Plan doo Fax SH14147056 1950350007 MORRISON WELL CONTAMINATION SFITECH GE MORRISON FACILITY WORK PLAN CONSENT ORDER NO. 04 CH 28 GENERAL ELECTRIC ENERGY SCHENECTADY, NEW YORK Prepared For: GE Energy Propared By: MWH Americas, inc. @® mw sunDie a Berren wont RECEIVED 7 FEB 22 201 Project No. 1010616 {EPA/BOL February 2011 RELEASABLE FEB 24 29) REVIEWER aapSECTION ACRONYMS AND ABBREVIATIONS... 1.0 INTRODUCTION. 2.0 PROJECT BACKGROUND. 24 22 3.0 FIELD PROCEDURES. 3.4 TABLE OF CONTENTS SITE CONDITIONS ...... WORK PLAN REQUIREMENTS . PRIVATE WELL SURVEY... 3.2 GROUNDWATER MONITORING WELL, INSTALLATION AND SAMPLING... 3.3 34 35 3.6 4,0 REPORTING 5.0 SCHEDULE. 3.2.1 Monitoring Well Installation and Develogmen 3.2.2. Monitoring Well Sampling .. a SOIL INVESTIGATION 7 DECONTAMINATION PROCEDURES........ INVESTIGATIVE DERIVED WASTE MANAGEMENT. SAMPLING PARAMETERG....... LIST OF TABLES Table 1 Sample and Analysis Plan LIST OF FIGURES Figure 1 Site Location Map Figure 2. Private Well Survey Locations Figure 3 Proposed Monitoring Well Locations Figure 4 Proposed Soil Boring Locations APPENDICES Appendix A Private Well Survey Questionnaire Work Plan ‘Consant Order No. 04 CH 28 7 GE Morrison Facility Morrison, tlinotsASTM bes VOCs DPT EPA FOC FSI GE Geotrans iDW MS. MSD PCE PDB PID PPE PVC ac Site TACO TCE g/t Vvots 1,1-DCE" 1,1,1-TCA Work Pian ACRONYMS AND ABBREVIATIONS American Society for Testing and Materials Below ground surface Chlorinated volatile organic compounds Direct push technology Environmental Protection Agency Fraction organic carbon Focused site investigation General Electric Company Geotrans, inc. Investigative derived waste Matrix spike Matrix spike duplicate Tetrachloroethene Passive diffusion bag Photo-ionization detector Personal protective equipment Polyvinyl! chloride Quality control GE Morrison Facility Tiered Approach to Corrective Action Objectives Trichloroethene micrograms per liter Volatile organic compounds 1,1-dichloroethene 1,1,1-trichloroethane GE Morrison Facility ‘Consent Order No. 04 GH 28 7 Morrison, ilinois4.0 INTRODUCTION This Work Plan presents the field activities for a soil and groundwater investigation at the GE Morrison Facility (Site) located in Morrison, Illinois (Figure 4). This Work Plan is prepared in accordance with Consent Order No. 04 CH 28 between the State of Iilinois and General Electric Company (GE), which was entered on December 23, 2010. The Illinois Environmental Protection Agency (EPA) is the administrative agency for the State of Illinois. Section C (Future Compliance) of the Consent Order mandates several components of work that need to be completed at the site, under an approved Work Plan. The Consent Order requires the following activities: * Asurvey of the homes west of Heaton Street and south of Morris Avenue to ascertain whether residents are using private wells. © The installation and sampling of two new monitoring wells. * Completion of soil borings and collection of soil samples near two former degreaser units, This Work Plan presents a summary of the project background, an outline of the field sampling procedures, a description of the reporting and data evaluation requirements for the project, and a schedule for completing the work, Work Plan GE Mortison Facility ‘Consent Order HB 7 a ~ Morrison, Hinois2.0 PROJECT BACKGROUND 2.1 SITE CONDITIONS General Electric Company has operated a manufacturing facility in Monson, Illinois, from the late 1940's until 2010. The facility manufactured components for motors and motor control equipment that were assembled at other locations. Prior to 1994 GE used chlorinated organic solvents for removing oil from the components prior to subassembly into units for installation in the final product. The degreasing ‘operations occurred in the Main Building (Building No. 1) at two separate locations: @ small immersion tank degreaser and at a larger continuous process line degreaser. |n 1986, chlorinated volatile organic compounds (CVOCs) were detected in the City ‘of Morrison water supply wells located near Rock Creek on the south side of Morrison. in 1987 GE, under illinois EPA oversight, installed and sampled eight groundwater monitoring wells in the unconfined aquifer in this area. CVOCs were detected in groundwater samples collected from three of the eight monitoring wells. Concentrations of | tricholorethene (TCE), _—tetrachlorothene (PCE), 1,1,1-etrachloroethane (1,1,1-TCA) and 1,1-dichlorosthene (1,1-DCE) exceeded Illinois EPA Tier 1 Groundwater Standards in the groundwater sample collected from G105D. The water supply wells are screened in a deeper con‘ined aquifer that is separated from the unconfined aquifer by the 350-foot thick Maquoketa Shale Layer. The Maquoketa shale is a hydrogeologic barrier between the shallower and deeper permeable formations’, A video survey was conducted down-hole In the three City water supply wells near Rock Creek in early 1988, The results showed a hole in the casing in one of the wells and water entering the well from the unconfined aquifer and migrating down 'Bers, R.C., Kempton, J.P., and Stecyk, A.N., 1984. Geology for Planning in Boone and Winnebago Counties. Ilinois Department of Energy and Natural Resources; prepared for State Geological Survey Division, Circular 531, Page 11 Work Pian i GE Morrison Facility 28 a Morrison, tlinois Consent Order Nithe, casing to the confined aquifer. In response to this observation, GE decommissioned two of the water supply wells (CW-1 and CW-2) in May 1988 to eliminate the interconnection between the upper and lower aquifer systems. One of the city.wells in the area, CW-3 was not abandoned, but an air stripper was installed by GE in September 1988 to treat water extracted from it. Six additional monitoring wells were installed by GE in the unconfined aquifer between the industrial area of Morrison (the west side of Morrison) and Rock Creek. This system of monitoring ‘wells has been sampled on a regular basis and the results show a decreasing trend in CVOC concentrations since 1988. in 1989, a soil gas survey was conducted beneath the floor slab at the Morrison Facility. Analysis of the soil gas samples indicated the presence of eight different CVOGs. The most commonly detected CVOCs were 1,1-DCE, TCE, 1,1,1-TCA and 1,1-dichloroethane. 1,1-DCE was detected at concentrations above 10,000 micrograms per liter (ug/L) and TCE was detected at concentrations above 1,000 Hg/L. The results indicated CVOCs may be present in either the soil or groundwater under the former western and eastern degreasers. tn 2001, Geotrans, inc. (Geotrans), under contract to GE, reviewed the results of the investigations conducted at the Site and the results from the groundwater monitoring. Geotrans also performed a natural attenuation study and concluded that residual VOCs in the unconfined aquifer between the west side industrial area of Morrison and Rock Creek would continue to degrade to below Class | groundwater standards over time. Geotrans recommended a groundwater management zone be considered for the portion of the unconfined aquifer between the west side industrial area and Rock Creek. Geotrans analysis of groundwater conditions indicated that groundwater flowed directly south towards Rock Creek and recommended the installation of two additional monitoring wells to complete the boundary of the groundwater management zone. Work Plan z GE Morrison Facility Consent Order No. G4 CH 28 22 ‘Morrison, Hinois|2.2 WORK PLAN REQUIREMENTS This Work Plan outlines the investigation activities to be performed at the Site in order to comply with the Consent Order. The investigation activities include: * Conducting a private well survey to determine if residents of the homes west of Heaton Street and south of Morris Avenue are utilizing private potable wells, * Installing two new downgradient monitoring wells and collecting and analyzing groundwater samples for volatile organic compounds (VOCs) by USEPA Method 8260. + Conducting a soil investigation beneath the two former degreaser areas by drilling soil borings at these locations, collecting soil samples, and submitting them for laboratory analysis for VOCs by USEPA Method 8260. * Prepare a Focused Site Investigation (FS!) Report that summarizes the results of the investigation activities described above, Work Plan GE Morrison Facility. ‘Consent Order No. 04 GH 28 a ‘Morrison, ilinois3.0 FIELD PROCEDURES This section of the Work Plan presents the field procedures that will be used during the private well survey, monitoring well installation, and soll and groundwater sampling activities, and defines the laboratory and quality control procedures that will be used during the investigation. 3.1. PRIVATE WELL SURVEY The private well survey will be conducted to determine if residents of the homes west of Heaton Street and south of Morris Avenue are utilizing private potable welis. Approximate 82 properties are located within the search area (Figure 2). The private well survey will be performed in the following manner: 1) A questionnaire will be mailed to each individual residen: in the survey area with return stamped postcard reply; 2) Attempt to conduct a telephone interview with individual residents who have not retumed the mailer; and, 3) Review City of Morrison Public Water Records to determine if a property of interest receives a water bill. If it cannot be determined whether a resident is utilizing a private water well (using the methods above) then an attempt will be made to meet the resident with the following procedure’ * Attempt to contact by visiting a weeknights; \gle homeowner twice over two consecutive * Attempt to contact by visiting the homeowner only during daylight hours: + Two personnel will be present at all times while contacting homeowners; + Personne! will not cross the threshold of homes or enter beckyards; Work Plan fea Consent Order No. 04 GH GE Morrison Facility. si Morrison, linoisThe survey will not be performed if there exists (or is perceived) any threat or danger to personnel from a resident, canine, or any other conditions {as deemed by the opinion of the personnel conducting the survey). If a private well status cannot be determined after attempting all the procedures listed above, that address will be documented and reported to the Illinois EPA as undetermined for their consideration 3.2 GROUNDWATER MONITORING WELL INSTALLATION AND SAMPLING 3.2.1. Monitoring Well Installation and Development Two new monitoring wells will be installed at the locations shown on Figure 3. Boart Longyear will install the monitoring wells and a MWH field geologist will oversee the drilling activities. The monitoring wells will be drilled using roto-sonic diling method The boreholes will be logged by the field geologist using the United Soil Classification System and the stratigraphy will be recorded on boring log forms. The monitoring wells will be constructed of 2-inch inner diameter stainless steel with a 10-foot screen. The monitoring wells will be screened at the bottom of the unconfined aquifer immediately above the bedrock surface in the sand and gravel layer. The monitoring wells will be finished with a flush-mounted surface completion and locking polyvinyl chloride (PVC) cap. Each new monitoring well will be developed using.a submersible pump after 2 minimum waiting period of 24 hours after completing installation of the monitoring well. Each well screen will be surged in an attempt to suspend and remove sediments that have settled after well installation has been completed. The well will be considered developed following the removal of at least three well volumes. Well volumes will be calculated based on depth to water measurements and well construction details. Work Plan GE Mortison Facility Consent Order No. 04 CH 28 ae Morrison, ifincis3.2.2 Monitoring Well Sampling Groundwater sampling of the two new monitoring wells will be completed during two ‘mobilizations to the Site. During the first visit, depth-to-groundwater measuremenis will be collected and passive diffusion bag (PDB) samplers will be deployed. PDB samplers will be allowed to remain in the wells for at least 14 days before the second visit to remove and collect samples from the PDBs. The following procedures will be used to deploy, recover, and collect groundwater samples from the PDB samplers. A dedicated PDB sampler apparatus consisting of stainless steel aircraft cable with clips for holding the PDB tethers (mesh sleeves in which the bags are placed) and a stainless steel weight for lowering the PDB to the screen midpoint will be placed in each new monitoring well PDB Deployment 1, Fill the pre-assembled PDB samplers with laboratory grade de-ionized water (approximately 200 milliliters). The sampler should be filled until water rises and stands at least half way into the funnel. Remove excess bubbles from the sampler and seal the PDB sampler. Laboratory prepared PDB samplers will be used in lieu of filing PDB samplers in the field 2. Lower the weight, line, and PDB sampler down the welll until the weight rests at the bottom and the line above the weight is taut. The PDB samplers should now be positioned at the midpoint of the well screen. 3. Secure the assembly in this position using the locking well cap connected to the line, Reattach the well cap. 4, Allow the system to remain undisturbed as the PDB samplers. equilibrate for a minimum of 14 calendar days. Work Plan GE Morrison Facility ‘Consent Order No. 04 CH 28 33) Morrison, IllinoisGroundwater Sample Collection 1. For sample collection, remove the PDB samplers from the well using the attached line. Do not place the PDB sampler on the ground. Do not expose the PDB sampler to ambient conditions for an extended time. 2. Detach and remove the PDB sampler from the weighted line. Remove the ‘excess liquid from the exterior of the bag with a clean towel to minimize the potential for cross contamination. 3. Using the sampling straw provided with the PDB sampler, transfer the groundwater to the sample containers (40 milliliter glass vials, pre-preserved with hydrochloric acid) provided by the laboratory 4, Monitoring well samples will be labeled GW-MDXX-20XX, where "MDXX" is the monitoring well designation and “20XX" is the year in which the sample was collected. 5. Place the filled sample containers in a cooler with ice for shipment to the laboratory under chain of custody. 6. The used PDB samplers will be contained in a plastic trash bag and disposed of offsite as general refuse. 3.3. SOIL INVESTIGATION Soil borings will be advanced and soil samples collected beneath the two former degreaser areas. Ten soil borings will be completed to a depth of 20 feet below ground surface (bgs) or to the water table (whichever is encountered first) near the ‘two former degreaser locations. One soil boring will be advanced in the center and four soil borings will be advanced approximately 15 to 20 feet off-center (to bracket the area) at each former degreaser location. Soil boring locations are shown on Figure 4. Work Plan ___GE Morrison Facility Consent Order No. 04 CH 2B ae ‘Worrison, ilinolsPSA Environmental of Lee's Summit, Missouri wil perform the diiling activities, The soil borings will be advanced using direct push technology (DP7). Soil borings will be logged by a geologist and field screened with a photo-ionization detector (PID) for VOCs. Two soil samples will be collected from each boring for VOC analysis by USEPA Method 8260. One soil sample will be collected at the interval with the highest PID reading and the other sample will be collected directly above the water table or at the terminus end of the boring if groundwater is not encountered. if no PID readings are observed, one soil sample will be collected at 5 feet bgs and the other sample will be collected directly above the water table or atthe terminus end of the boring if groundwater is not encountered. Soil Sample Collection 1. Soil cores will be extracted in disposable acetate sleeves. 2. The acetate sieves will be cut and opened so the geologist can describe the soils for the boring log and screen the core for VOCs. 3. The acetate sleeves will be sealed in clean tinfoil wrap to ensure VOCs do not escape while the boring is completed to depth (maximum depth of 20 feet) 4. Following completion of the soil boring grab soil samples will be collected and Placed into laboratory provided sample containers. Samples for VOC analysis will be field preserved using a methanol field preservation sample kit, 5. Soil samples will be labeled SO-SBXX-YY, where “SBXX" is the soil boring designation and "YY" is the depth from which the sample was collected. 6. Each sample will be piaced in a cooler with ice for shipment to the laboratory under chain of custody. 7. The used acetate liners will be contained in a plastic trash bag and disposed of offsite as general refuse. Werk Plan ____GE Morrison Facility Consent Order No. 04 CH 28 3 Mortison, ilinoisUp to four soil samples will be collected for physical characteristics and geotechnical testing during the soil investigation. Sampling locations and depths for physical and geotechnical characteristics will be determined in the field by the supervising geologist. These samples will be submitted to the laboratory and placed on hold pending the analytical results of the samples collected near the degreasers. If the samples near the degreasers indicate the soils contain CVOCs above applicable standards, then the samples for physical and geotechnical characteristics will be analyzed. The samples for physical characteristics will be used to evaluate remedial altematives and for use as inputs into soil and groundwater calculations (such as Ieaching potential) Four background soil samples will be collected for fraction organic carbon (FOC). Background soil borings will be advanced at the locations illustrated on Figure 4. Two soil borings will be advanced and two soil samples will be collected from each boring for a total of four soil samples. One soil sample will be collected at 5 feet bgs and the other sample will be collected directly above the water table or at the terminus end of each boring if groundwater is not encountered. Additional sample volume will be collected and analyzed for VOCs and semi-volatile organic compounds (SVOCs) to confirm each sample is representative of actual background FOC conditions and is not elevated by anthropogenic sources of organic carbon. The soil sample will be considered representative of backgrourd soil conditions if VOC concentrations are below the method detection limit and SVOG concentrations are below the background soil concentrations for polynuclear aromatic hydrocarbons listed in Part 742, Appenix A, Table H of the Tiered Approach to Corrective Action Objectives (TACO). Following completion of the soil borings, the boreholes will be backfilled with bentonite chips.. 3.4 DECONTAMINATION PROCEDURES Driling equipment used for monitoring well installation will be decontaminated before and after drilling and between each borehole. Drilling equipment will be decontaminated by steam cleaning on a decontamination pad that will be Work Pian _ : GE Morrison Facility Consent Order No. 04 GHB 36 ‘Morrison, ilinoisconstructed to contain decontamination fluids. Downhole equiprent used for drilling soil borings will be cleaned before beginning Site activities and between boring locations using a non-phosphate wash (Alconox® or similar) and distilled water rinse. The water level meter used for collection of groundwater elevations will be decontaminated before and between each use using an Alconox® wash and distilled water rinse, Groundwater sampling equipment is single use and is not transferred between wells. The PDBs are disposable and the PDB tethers will be stored inside the wells between sampling events. Sampling containers will be received from the laboratory pre-cleaned and contaminant free. 3.5 INVESTIGATIVE DERIVED WASTE MANAGEMENT Investigative derived waste (IDW) will consist of soil cuttings from monitoring well installation and soil boring activities, purge water from monitoring well development activities, decontamination water from drilling equipment, decontamination water from the water level measurement device, excess water from ®DB sample bags, personal protective equipment (PPE), puncturing tubes for the sampling, used PDB sample bags, and used sample liners for soil sampling, The IDW will be handled according to the waste stream characteristics as follows: * Soil cuttings from well installation and soil boring activities will be contained in 55-gallon drums and stored on-site in a location designated by Site personnel. The drums will be labeled with the date, contents, and Site name. One composite sample will be collected at the end of the investigation 's from the soil IDW and submitted to the laboratory for analysis of waste characterization parameters, + Liquid IDW consisting of decontamination water from driling equipment and purge water from monitoring well development will be contained in 55-gallon drums and stored on-site in a location designated by Site personnel. The drums will be labeled with the date, contents, and Site name. One composite sample will be collected at the end of the investigation activities from the Work Pian = GE Morrison Factity ‘Consent Order No, 04 GH 28 37 Morrison, Hingisliquid DW and submitted to the laboratory for analysis of waste characterization parameters, * Decontamination water will be generated in limited quantities during cleaning of the water level meter, and minor amounts of excess groundwater may be present in the PDB sample bags. This de minimus quantity of water will not containerized with the development water. * PPE will consist of nitrile gloves used during the soll and groundwater sampling activities. PPE will be contained in plastic trash bags and disposed offsite as general refuse. * Puncturing tubes, used PDB sample bags, and used semple liners will be Contained in plastic trash bags and disposed offsite with general refuse. 3.6 SAMPLING PARAMETERS Groundwater samples will be analyzed for VOCs by USEPA SW-846 Method 82608. Soil samples collected in the former degreaser areas will also be analyzed for VOCs. by the same method. Soil samples collected for physical and geotechnical characteristics will be analyzed for Atterberg limits by American Society for Testing and Materials (ASTM) Method 04943, grain size (ASTM 01422), soil moisture content (ASTM 02216), soil moisture retention (ASTM 02325), tctal porosity (ASTM 0854/2937), soil dry bulk density (ASTM 2937), and permeabilty (ASTM 02434) Background soil samples will be analyzed for VOCs by USEPA SW-846 Method 8260B, SVOCs (USEPA SW-846 Method 8270C), and FOC (ASTM Method 2974). Upon completion of the investigation activities, composite soil and water samples will be collected from the drums of IDW and will be analyzed for waste characterization Parameters for the purpose of determining proper disposal procedures. Composite soil IDW samples will be analyzed for the following waste characterization parameters: Work Pian ee GE Morrison Facility Consent Order No, 04 CH 28 38 ‘Morrison, ilinois© TCLP VOCs (SW-846 82608); * TCLP SVOCs (SW-846 8270C); * TCLP Metals ~ RCRA List (SW-846 60108/SW7470A); © Reactive Cyanide (ASTM D5049; and * Reactive Sulfide (ASTM D4978). Composite liquid IDW samples will be analyzed for the following waste characterization parameters: * VOCs (SW-846 82608); * SVOCs (SW-846 82700); * Total Metals - RCRA List (SW-846 6010B/SW7470A); * pH (SW-846 9040/9045); ‘+ Flashpoint (SW-846 1010); * Total Cyanide (EPA 9012); and * Total Sulfide (EPA 376.1). Quality Control (QC) samples will be collected for soil and groundwater samples. QC samples include field duplicates, matrix spike (MS), and matrix spike duplicate (MSD). In addition, trip biank samples will be included with the groundwater samples in the cooler and an equipment blank sample of the de-ionized water will be analyzed for VOCs. A summary of the analytical methods, QC criteria, and number of samples to be collected for each task associated with this Work Plan is provided in Table 1. Work Pian __GE Morrison Facility ‘Consent Order No. 04 CH 28 ao fee Morrison, tilinois4.0 REPORTING ‘A Focused Site Investigation (FSI) Report will be prepared following completion of field work. The report will summarize the results of the work conducted pursuant to this Work Plan. The FSI Report will include a Tier 2 evaluation of soil concentrations beneath the former degreasers. The FSI Report will be prepared in accordance with the report guidelines provided in Exhibit B of the Consent Order. Five Agency review copies of the FSI Report will be provided to the State of lilinois distribution list defined in the Consent Order. Work Plan zB GE Morrison Facility ‘Consent Order No. 04 GH 26 ei Morrison, ilinois5.0 SCHEDULE The investigation activities mandated in the Consent Order (1e. private well survey, monitoring well installation and sampling, and soil investigation beneath the two former degreaser areas) will be completed within 60 days of Hlinois EPA approval of this Work Plan. The Agency review draft of the FSI Report summarizing these investigation activities will be submitted to the illinois EPA within 180 days of Hlinois EPA approval of this Work Plan. JEBDPPPIDLOILMCIAKS “s10800-101O89A 070616 GE Moreon\L0 Esecston Project OelvelsleyM.2 Work PliMorison Wok Fak Agony doe Work Pian _ _GE Morrison Faclity Consent Order No. 04 CH 2B a Morrison, ilinoisTABLEFIGURESauton Fal lSobeutace Sal Sorina — [sae DEO SaaS] Seats soa W505 pst p2504 | sitions Ai OBe4 27 ‘ASTM Eze swasigaive Deed WasteMORRISON, ILLINOIS FIGURE 1 - SITE LOCATION MAP. GENERAL ELECTRIC ENERGY 709 WEST WALL STREET LOCATION SITE ee ( 3 \aEES i COMI} [ MAIN. BUILDING FIRST FLOOR eeAPPENDIX AWATER WELL SURVEY QUESTIONNAIRE 1 Name: 2 Address: Ee eee eee Egg LEELELEE 3. Telephone Number: pectin 4. How long have you lived at the above address? 5. Property owner if different than above i 6. _Is there a septic system installed and operating on your property? j Yes No __ Unknown 7. Describe location and details of septic system. | 8 Is here a well on the property? Yes No Unknown, {if no or unknown stop here) 9. Is the well operable Yes No? (ifno, stop here.) 10, If the answer to Question 9 is Yes, what Is the well used for? (Check ali that apply) A) Domestic Use: (a) Drinking Water (b) Wash water (c) Irrigation {d) Other (Explain) {8} Commercial/industriav/Agricultural Use i {a) Animal Husbandry \ {b) Irrigation (6) Drinking (8) Manufacturing {e) Other (Explain) 11. How was the well constructed? Hand Dug __ Drilled Unknown 12, Weihead completion type? Check: a) Below-ground pit ‘oF below-ground pitless adaptor b) Depth of well casing or adaptor below ground d ©) Other _13. Do you have a water softener, iron filter, carbon filter, or other water treatment system installed? a Yes ___No Unknown, 14. Well casing material 18. Well Depth? 16. Date well was instalied? 47. Drilling company and address (if known) 18. Tye of pump eabainbareaseneseteeens sons aandatsnteanaatsnieasdat SanISeee SSISERS gC =] submersible, jet puma) 18, Doyou have any additional comments regarding your water supply at this time? 20. If awell is present sketch the location of well relative to existing structures. Also sketch the location of the septic system if present.