Drought Economic Impact Survey for Institutional, Commercial, Industrial, Public Water System and Agricultural Water Users

As part of the state's emergency response efforts to the drought, New Hampshire Department of Environmental Services (NHDES) is gathering information related to private well water availability and drought related economic impacts. The information requested in the below survey will assist the state in identifying the location and severity of drought impacts for assessing drought response needs.

Who should submit this form?

Industrial, commercial, institutional and agricultural water users on private wells experiencing problems with water supply due to the ongoing drought or who were experiencing problems, but made repairs to mitigate water supply issues. (This does not include water users solely on public water systems.)

Why is the information needed?
-To identify and assess drought response needs of those not served by public water systems.

-To identify where adverse impacts associated with drought are occurring.

-To quantify the specific economic impacts associated with drought to support potential disaster assistance requests.

Additional Information:
Collection of data is not to be construed as application for local, state or federal assistance.

NHDES intends to use this information for the reasons stated above. Please note that information submitted to the NHDES is considered to be part of the public record. NHDES will not publish your information, but other entities conducting Right-to-Know requests may be able to access the information you provide.

Thank you in advance for your time.

1.Contact Information(Required.)

First Name:

Last Name:

Company/Organization Name:

Public Water System ID (if applicable):

Water User ID (if applicable):

Phone Number:

E-mail:

2.Please describe the water issue that you had/are having? (Check all that apply.)(Required.)

Well is dry and no longer producing water.

Well pump is intermittently sucking air. Need to wait for the well to recharge to be able to pump again.

Well is pumping sand and/or muddy water.

Water pressure is low and/or you are experiencing lower flows out of fixtures or equipment.

Water quality has been reduced.

Stream/river flow is too low to pump water.

Lake/pond level is too low to pump water.

Other (please specify)

3.What is the approximate date that the above problem started?(Required.)

Date

SuSunday

MoMonday

TuTuesday

WeWednesday

ThThursday

FrFriday

SaSaturday

5.If you tried to repair the problem, but the solution did not work, please describe what happened.

6.What was the cost of the repair ($)?(Required.)

If this does not apply to you, enter "X":

7.Who completed the repair work?(Required.)

If this does not apply to you enter "X":

8.Outside of the cost of repair, what do you estimate the economic impact has been to your business and how did you come to this estimate?(Required.)

Economic Impact ($):

Explanation of how economic impact was estimated:

10.Does the water user own or rent the property that the water use occurs on?

(Required.)

Own

Rent

Other:

11.What type of surface water has been impacted by the drought?(Required.)

Stream/River

Lake/Pond

Does not apply as the water source is a well.

Name of Surface Water:

12.What type of well has been impacted by the drought? (For well definitions, click here.)(Required.)

If more than one well has been impacted, please specify the number of wells and type of wells:

13.Well Information: (If you do not know this information, please leave blank. If your well was drilled after January 1, 1984, the below information may be found on the DES OneStop Data search. Click on "Water Well" and type in street address information.

Depth of well:

Year well was drilled:

If more than one well was impacted, please provide information for other wells:

14.Well/Surface Water Location:(Required.)

Street Number:

Street Name:

City:

Zip:

Two nearest crossroads:

If more than one water source has been impacted, please provide any additional location information of all sources:

15.Comments

Drought Economic Impact Survey for Institutional, Commercial, Industrial, Public Water System and Agricultural Water Users

Last Update: June 2018