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42-39-6
10/2010
I iM III: Is].I.IfellI F7W-1
A. Injection Well Name or ID from Construction Plans: Infiltration Gallery No. 1
B. Injection Well Design:
❑✓ Infiltration Gallery ❑ French Drain ❑ Pre -cast Open Bottom Dry Well
❑ Cased Injection Well ❑ Other
(include drawing with form)
Construction Date (indicate Actual, Approximate or Anticipated): SUMMER/FALL 2015
C. Pre -Treatment:
❑ Sediment Basin✓❑ Sand Filtration ❑ Vegetative Filter Strip or Swale
❑✓ Oil & Grease Trap ❑ Sand & Grease Trap ❑✓ Other FLEXSTORM INSERT
D. Injection Well Dimensions:
Length 80 (ft) Width 32 (ft)
III. LOCATION INFORMATION
Depth 3
A. Well Location: (Provide one of the following two options)
1) GPS Location (Datum = WGS84):
Latitude 43°33'26.09"N Longitude 116°20'42.41"W
(ft)
(You can check the accuracy of your GPS data with the "Well Diller's Locator Tool" here:
"http://maps.idwr.idaho.gov/locator/default.aspx")
2) A USGS Topographic Map or aerial photo with the well location marked AND Township,
Range, Section information.
Township Range Section Y,4,'/.. Y, Section Y. Y Section %< Section
i
I
(Get free maps using this tool: http://maps.idwr.idaho.gov/lrrigationRightsFinder)
B. If State or Local Highway Entity:
Distance Direction To Milepost No. Hwy. No.
❑ East Bound Lane ❑ West Bound Lane ❑ Median
C. Is the Well/Facility Located on Indian Lands? ❑ Yes✓❑ No
2of4
42-39-6
10/2010
IT�III xd:1zILOU 087_1"
A. Injection Well Name or ID from Construction Plans: Infiltration Gallery No. 2
B. Injection Well Design:
❑] Infiltration Gallery ❑ French Drain ❑ Pre -cast Open Bottom Dry Well
❑ Cased Injection Well ❑ Other
(include drawing with form)
Construction Date (indicate Actual, Approximate or Anticipated): SUMMER/FALL 2015
C. Pre -Treatment:
❑ Sediment Basin ❑✓ Sand Filtration ❑ Vegetative Filter Strip or Swale
❑✓ Oil & Grease Trap ❑ Sand & Grease Trap ✓❑ Other FLEXSTORM INSERT
D. Injection Well Dimensions:
Length 70 (ft) Width 32 (ft)
III. LOCATION INFORMATION
Depth 3
A. Well Location: (Provide one of the following two options)
1) GPS Location (Datum = WGS84):
Latitude 43°33'25.55"N Longitude 116°20'43.91"W
(ft)
(You can check the accuracy of your GPS data with the "Well Diller's Locator Tool" here:
"http://maps.idwr.idaho.gov/locator/default.aspx")
2) A USGS Topographic Map or aerial photo with the well location marked AND Township,
Range, Section information.
(Get free maps using this tool: http://maps.idwr.idaho.gov/lrrigationRightsFinder)
B. If State or Local Highway Entity:
Distance Direction _ To Milepost No. Hwy. No.
❑ East Bound Lane ❑ West Bound Lane
C. Is the Well/Facility Located on Indian Lands? ❑ Yes
2of4
❑ Median
❑✓ No
42-39-6
10/2010
II. TECHNICAL DATA
A. Injection Well Name or ID from Construction Plans: Infiltration Gallery No. 3
B. Injection Well Design:
❑✓ Infiltration Gallery ❑ French Drain ❑ Pre -cast Open Bottom Dry Well
❑ Cased Injection Well ❑ Other
(include drawing with form)
Construction Date (indicate Actual, Approximate or Anticipated): SUMMER/FALL 2015
C. Pre -Treatment:
❑ Sediment Basin ❑✓ Sand Filtration ❑ Vegetative Filter Strip or Swale
❑✓ Oil & Grease Trap ❑ Sand & Grease Trap ❑✓ Other FLEXSTORM INSERT
D. Injection Well Dimensions:
Length 70 (ft) Width 40 (ft) Depth 3 (ft)
III. LOCATION INFORMATION
A. Well Location: (Provide one of the following two options)
1) GPS Location (Datum = WGS84):
Latitude 43°33'25.11"N Longitude 116°20'46.54"W
(You can check the accuracy of your GPS data with the "Well Diller's Locator Tool" here:
"hftp://maps.idwr.idaho.gov/locator/default.aspx")
2) A USGS Topographic Map or aerial photo with the well location marked AND Township,
Range, Section information.
(Get free maps using this tool: http://maps.idwr.idaho.gov/IrrigationRightsFinder)
B. If State or Local Highway Entity:
Distance Direction To Milepost No. Hwy. No.
❑ East Bound Lane ❑ West Bound Lane ❑ Median
C. Is the Well/Facility Located on Indian Lands? ❑ Yes ❑✓ No
2of4
42-39-6
10/2010
TIM I =191: 1,04 1[9_1A ■L'r El
A. Injection Well Name or ID from Construction Plans: Infiltration Gallery No. 4
B. Injection Well Design:
❑� Infiltration Gallery ❑ French Drain ❑ Pre -cast Open Bottom Dry Well
❑ Cased Injection Well ❑ Other
(include drawing with form)
Construction Date (indicate Actual, Approximate or Anticipated): SUMMER/FALL 2015
C. Pre -Treatment:
❑ Sediment Basin✓❑ Sand Filtration ❑ Vegetative Filter Strip or Swale
❑✓ Oil & Grease Trap ❑ Sand & Grease Trap ❑✓ Other FLEXSTORM INSERT
D. Injection Well Dimensions:
Length 70 (ft) Width 24 (ft)
III. LOCATION INFORMATION
Depth 3
A. Well Location: (Provide one of the following two options)
1) GPS Location (Datum = WGS84):
Latitude 43°33'24.48"N Longitude 116°20'48.40"W
(ft)
(You can check the accuracy of your GPS data with the "Well Diller's Locator Tool" here:
"http://maps.idwr.idaho.gov/locator/default.aspx")
2) A USGS Topographic Map or aerial photo with the well location marked AND Township,
Range, Section information.
(Get free maps using this tool: http://maps.idwr.idaho.gov/lrrigationRightsFinder)
B. If State or Local Highway Entity:
Distance Direction _ To Milepost No. Hwy. No.
❑ East Bound Lane ❑ West Bound Lane
C. Is the WeII/Facility Located on Indian Lands? ❑ Yes
2of4
❑ Median
❑✓ No
42-39-6
10/2010
II. TECHNICAL DATA
A. Injection Well Name or ID from Construction Plans: Infiltration Gallery No. 5
B. Injection Well Design:
❑� Infiltration Gallery ❑ French Drain ❑ Pre -cast Open Bottom Dry Well
❑ Cased Injection Well ❑ Other
(include drawing with form)
Construction Date (indicate Actual, Approximate or Anticipated): SUMMER/FALL 2015
C. Pre -Treatment:
❑ Sediment Basin Sand Filtration ❑ Vegetative Filter Strip or Swale
❑✓ Oil & Grease Trap ❑ Sand & Grease Trap ❑✓ Other FLEXSTORM INSERT
D. Injection Well Dimensions:
Length 58 (ft) Width 30 (ft) Depth 3 (ft)
III. LOCATION INFORMATION
A. Well Location: (Provide one of the following two options)
1) GPS Location (Datum = WGS84):
Latitude 43'33'26.09"N Longitude 116°20'48.96"W
(You can check the accuracy of your GPS data with the "Well Diller's Locator Tool" here:
"hftp://maps.idwr.idaho.gov/locator/default.aspx")
2) A USGS Topographic Map or aerial photo with the well location marked AND Township,
Range, Section information.
Township Rang e Sect1. ion j Y. %'/,Section %..'/.Section %Section
(Get free maps using this tool: http://maps.idwr.idaho.gov/lrrigationRightsFinder)
B. If State or Local Highway Entity:
Distance _ Direction _ To Milepost No. Hwy. No.
❑ East Bound Lane ❑ West Bound Lane
C. Is the Well/Facility Located on Indian Lands? ❑ Yes
2of4
❑ Median
❑✓ No
42-39-6
10/2010
II. TECHNICAL DATA
A. Injection Well Name or ID from Construction Plans: Infiltration Gallery No. 6
B. Injection Well Design:
❑✓ Infiltration Gallery ❑ French Drain ❑ Pre -cast Open Bottom Dry Well
❑ Cased Injection Well ❑ Other
(include drawing with form)
Construction Date (indicate Actual, Approximate or Anticipated): SUMMER/FALL 2015
C. Pre -Treatment:
❑ Sediment Basin✓❑ Sand Filtration
❑✓ Oil & Grease Trap ❑ Sand & Grease Trap
D. Injection Well Dimensions:
Length 34 (ft) Width 14 (ft)
III. LOCATION INFORMATION
❑ Vegetative Filter Strip or Swale
❑✓ Other FLEXSTORM INSERT
Depth 3
A. Well Location: (Provide one of the following two options)
1) GPS Location (Datum = WGS84):
Latitude 43°33'27.55"N Longitude 116°20'47.51"W
(ft)
(You can check the accuracy of your GPS data with the "Well Diller's Locator Tool" here:
"hftp://maps.idwr.idaho.gov/locator/default.aspx")
2) A USGS Topographic Map or aerial photo with the well location marked AND Township,
Range, Section information.
ToT wnship Range Section /4.
/. '/4 Section /4. %. Section /. Section
(Get free maps using this tool: hftp://maps.idwr.idaho.gov/lrrigationRightsFinder)
B. If State or Local Highway Entity:
Distance Direction _ To Milepost No. Hwy. No.
❑ East Bound Lane ❑ West Bound Lane
C. Is the Well/Facility Located on Indian Lands? ❑ Yes
2of4
❑ Median
❑✓ No
42-39-6
10/2010
U. TECHNICAL DATA
A. Injection Well Name or ID from Construction Plans: Infiltration Gallery No. 7
B. Injection Well Design:
❑✓ Infiltration Gallery ❑ French Drain ❑ Pre -cast Open Bottom Dry Well
❑ Cased Injection Well ❑ Other
(include drawing with form)
Construction Date (indicate Actual, Approximate or Anticipated): SUMMER/FALL 2015
C. Pre -Treatment:
❑ Sediment Basin ❑✓ Sand Filtration ❑ Vegetative Filter Strip or Swale
❑✓ Oil & Grease Trap ❑ Sand & Grease Trap ❑✓ Other FLEXSTORM INSERT
D. Injection Well Dimensions:
Length 10 (ft) Width 4 (ft) Depth 3 (ft)
III. LOCATION INFORMATION
A. Well Location: (Provide one of the following two options)
1) GPS Location (Datum = WGS84):
Latitude 43'33'23.84"N Longitude 116°20'49.34"W
(You can check the accuracy of your GPS data with the "Well Diller's Locator Tool" here:
"hffp://maps.idwr.idaho.gov/locator/default.aspx")
2) A USGS Topographic Map or aerial photo with the well location marked AND Township,
Range, Section information.
Township Range Section Y4 Y4 Y4 Section Y4. Y44 Section /. Section
(Get free maps using this tool: http://maps.idwr.idaho.gov/lrrigationRightsFinder)
B. If State or Local Highway Entity:
Distance Direction _ To Milepost No. Hwy. No.
❑ East Bound Lane ❑ West Bound Lane
C. Is the Well/Facility Located on Indian Lands? ❑ Yes
2of4
❑ Median
❑✓ No
42-39-6
10/2010
IV. WELL OPERATION
A. Constituents in Waste Stream:
❑ None ❑ Hazardous wastes ❑ Automotive fluids
❑ Pesticides ❑ Herbicides
❑✓ Other additives or chemicals Those typical of roadway and lot runoff.
B. Is the injection well part of with a contamination remediation system? ❑ Yes 2 No
If yes, please attach a copy of the signed regulatory approval for the remediation action and
intended use of the injection well.
V. ATTACHMENTS (Attach additional sheets as needed)
❑� Site Maps Showing Well Locations
0 Design Plans and Other Drawings or Schematics
❑ For Remediation Projects: Project Summary including Geology, Analysis Results,
Projection Description, Target Depth, and other applicable information.
0 If using BMP, Name of Agency and Technical Guidance Citation
Sand and Grease Trao. Flex Storm Inserts. and ASTM Filter Sand
❑ Other
VI. CERTIFICATION
I certify under penalty of law that there are no discharges of hazardous substances or other fluids in
amounts that may endanger an underground source of drinking water from the injection well(s)
identified on this inventory form.
Additionally, 1 certify under penalty of law that this document and all attachments were prepared
under my direction or supervision in accordance with a system designed to assure that qualified
personnel properly gathered and evaluated the information submitted. Based on my inquiry of the
person or persons who manage the system, or those persons directly responsible for gathering the
information, the information is to the best of my knowledge and belief true, accurate and complete.
am aware that there are significant penalties for submitting false information, including the possibility
of fine and imprisonment for knowing violations.
All sections of this form must be complete and accurate. Incomplete forms will be returned to
applicant. The information submitted is subject to verification by IDWR or its agents.
o ZZZ R
Ross Erickson' a� k� mm ° 111.
Date Signature
Print Name
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