State Small Water System Drought Response Facilitation Reporting Form

This form is intended to help the County gather information about challenges faced by State Small Water Systems due to ongoing drought conditions. The County's role is to facilitate communication and coordination with appropriate agencies or resources that may provide support. Please note that the County is not a water supplier and does not provide water or mitigation services unless explicitly funded and supported through Federal, State, or Local programs.

“State small water system” is defined as a system for the provision of piped water to the public for human consumption that serves at least five, but not more than 14, service connections and does not regularly serve drinking water to more than an average of 25 individuals daily for more than 60 days out of the year.

Section 1: System Information

Water System name * (required)

Contact Person's Name * (required)

Contact Person's Title/Position * (required)

Contact Person's Phone Number * (required)

Contact Person's Email Address * (required)

Preferred Contact Information * (required)

• Phone
• Email

System Location * (required)

Address or Nearest Cross Street or Other Location Description, including City and Zip Code

Type of Water Source * (required)

• Groundwater Well(s)
• Surface Water Diversion
• Spring

Other

Population Served by the System

Number of Connections/Households Served

Scetion 2: Water Supply Issue Details

Nature of the Problem * (required)

• Well(s) Going Dry
• Reduced Water Pressure
• Surface Water Supply Reduced or Stopped
• Water Quality Issue

Other

If you selected "Water Quality Issue" please describe

When Did the Issue Begin? * (required)When Did the Issue Begin? * (required)

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Actions Taken to Address the Issue

• Increased Water Conservation Measures
• Reduced Water Usage
• Hauled Water In
• Installed Temporary Storage Tanks

Other

Describe the Water Supply Issue: * (required)

(Provide details about the issue, such as low water levels, visible changes in flow, or other concerns.)

Additional Support or Information Needed:

(Indicate any specific requests for technical guidance, monitoring tools, etc. County will review the support request and provide recommendations and possible facilitation to communicate with appropriate agencies/entities that could provide such support. Please note that the County is not a water supplier and does not provide water or mitigation services unless explicitly funded and supported through Federal, State, or Local programs.)

Section 3: Well Details [Skip this section if your system uses surface water division]

Number of Active Wells

Depth of Affected Wells in Feet (Include Separate Numbers for Each Well)

Construction Date for Each Well

Additional Comments About Wells

Section 4: Sruface Water Details [skip this section if you use groundwater wells]

Water Source:

(E.g., river name, canal, reservoir, spring)

Type of Diversion:

• Direct Diversion (Pump/Intake)
• Gravity Diversion

Additional Comments about Surface Water Supply and Type of Support Needed

(Indicate any specific requests for technical guidance, monitoring tools, etc. County will review the support request and provide recommendations and possible facilitation to communicate with appropriate agencies/entities that could provide such support. Please note that the County is not a water supplier and does not provide water or mitigation services unless explicitly funded and supported through Federal, State, or Local programs.)

Section 5: Submission Details

Form Submitted By: * (required)

Title/Position:

If not submitted by Contact Person, Preferred Contact Method:

• Phone
• Email

Phone or Email:

Type the characters you see in the image below * (Required)

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