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PWS ID / FACILITY ID 1020035 SO2 UNIQUE WELL NO. 416183 <br />PCSI <br />CODE <br />ACTUAL OR POTENTIAL <br />CONTAMINATION SOURCE <br />ISOLATION DISTANCES (FEET) <br />LOCATION <br />Minimum Distances <br />Sensitive <br />Well' <br />Within <br />200 Ft. <br />Y / N / U <br />Dist. <br />from <br />Well <br />Est. <br />(?) <br />Community <br />Non- <br />community <br />IWD <br />Industrial waste disposal well (Class V welly <br />illegal' <br />illegal' <br />N <br />IWS <br />Interceptor, including a flammable waste or sediment <br />50 <br />50 <br />N <br />OH1 <br />Ordinary high water level of a stream, river, pond, lake, reservoir, or <br />drainage ditch (holds water six months or more) <br />50 <br />35 <br />N <br />*PP1 <br />Petroleum buried piping <br />50 <br />50 <br />N <br />*PP2 <br />Petroleum or crude oil pipeline to a refinery or distribution center <br />100 <br />100 <br />N <br />PT1 <br />Petroleum tank or container, 1100 gal. or more, without safeguards <br />150 <br />150 <br />N <br />PT2 <br />Petroleum tank or container, 1100 gal. or more, with safeguards <br />100 <br />100 <br />N <br />PT3 <br />Petroleum tank or container, buried, between 56 and 1100 gal. <br />50 <br />50 <br />N <br />PT4 <br />Petroleum tank or container, not buried, between 56 and 1100 gal. <br />505 <br />20 <br />N <br />PU1 <br />Pit or unfilled space more than four feet in depth <br />20 <br />20 <br />N <br />PC1 <br />Pollutant or contaminant that may drain into the soil <br />50 <br />50 <br />100 <br />N <br />SP1 <br />Swimming pool, in -ground <br />20 <br />20 <br />N <br />*VH1 <br />Vertical heat exchanger, horizontal piping conforming to rule <br />50 <br />10 <br />N <br />*VH2 <br />Vertical heat exchanger (vertical) piping, conforming to rule <br />50 <br />35 <br />N <br />*WR1 <br />Wastewater rapid infiltration basin, municipal or industrial <br />300 <br />300 <br />600 <br />N <br />*WA1 <br />Wastewater spray irrigation area, municipal or industrial <br />150 <br />150 <br />300 <br />N <br />`WS1 <br />Wastewater stabilization pond, industrial <br />150 <br />150 <br />300 <br />N <br />*WS2 <br />Wastewater stabilization pond, municipal, 500 or more gal./acre/day of <br />leakage <br />300 <br />300 <br />600 <br />N <br />*WS3 <br />Wastewater stabilization pond, municipal, less than 500 gal./acre/day of <br />leakage <br />150 <br />150 <br />300 <br />N <br />*VVT1 <br />Wastewater treatment unit tanks, vessels and components (Package plant) <br />100 <br />100 <br />N <br />"WT2 <br />Water treatment backwash disposal area <br />50 <br />50 <br />100 <br />N <br />Additional Sources (If there is more than one source listed above, please indicate here). <br />Potential <br />Contamination Sources and Codes Based on Previous Versions of this <br />Form <br />SWD <br />Storm water drain pipe, 12 inches or greater <br />50 <br />20 <br />Y <br />80 <br />N <br />WAT <br />Stream, river, pond, lake, wetland <br />50 <br />50 <br />Y <br />150 <br />Y <br />FPH <br />Frost proof yard hydrant <br />10 <br />10 <br />Y <br />50 <br />N <br />New potential contaminant source. <br />A sensitive well has less than 50 feet of watertight casing, and which is not cased below a confining layer or confining materials of at least 10' in thickness. <br />These sources, known as Class V underground injection wells, are regulated by the federal U.S. Environmental Protection Agency. <br />These sources are classified as illegal by Minnesota Rules, Chapter 4725. <br />4 Isolation distance is determined by average flow per day or if a facility handles infectious or pathological wastes. <br />A community public water -supply well must be a minimum of 50 feet from a petroleum tank or container, unless the tank or container is used for emergency <br />pumping and is located in a room or building separate from the community well; and is of double -wall construction with leak detection between walls; or is protected <br />with secondary containment. <br />This form is based on the new isolation distances in Minnesota Rules, Chapter 4725, related to wells and borings adopted August <br />4, 2008, and Minnesota Rules, Chapter 4720, related to wellhead protection. <br />6/21/2019 <br />3 <br />