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Private Well Form Templates for Use by Local Boards of Health

Local boards of health or health departments may use these templates to create forms specific to your municipality or district.

Use of any of the following private-well-related forms is not required by any state statutes or regulations. MassDEP offers these templates as a courtesy to local boards of health and health departments knowing that many of you are using, or are interested in using, these types of templates. The templates are compatible with the contents of the current version of the "Model Board of Health Regulations for Private Wells." You may modify any of these forms to suit the needs of your municipality or health district.

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Open DOCX file, 32.5 KB,  Well Construction Permit Application Template (English, DOCX 32.5 KB)

You may use this template to design a well-drilling permit application for all types of private-well uses.

Open DOCX file, 34.49 KB,  Pumping Test Report Template (English, DOCX 34.49 KB)

You may use this template to design a pumping-test report form for an applicant to report the results of a private-well yield test. The main purpose of this form is to document the details of the pumping test for use in establishing the estimated volumetric well yield.

Open DOCX file, 30.2 KB,  Water Quality Report template (English, DOCX 30.2 KB)

You may use this template to design a form for an applicant to submit copies of laboratory analytical results for water samples collected from their private well.

Open DOCX file, 29.02 KB,  Water Supply Certificate Application Template (English, DOCX 29.02 KB)

You may use this template to design a form for a Water Supply Certificate applicant to use upon successful completion of well installation, well yield testing, and water-quality testing of the well.

Open DOCX file, 20.3 KB,  Water Supply Certificate Template (English, DOCX 20.3 KB)

Use this template to design a form for boards of health or health departments to use when issuing a Water Supply Certificate to indicate that the well construction, estimated yield, and water quality meet the municipality's or district's standards for the proposed private-well use.

Open DOCX file, 26.22 KB,  Covenant to Maintain Well Water Treatment Unit Template (English, DOCX 26.22 KB)

Use this template to design a form for boards of health or health departments to establish a legally-binding covenant between a well owner and the municipality to install and maintain a treatment unit for any contaminants in the well water that exceed the municipality's established allowable-contaminant concentration.

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MassDEP Drinking Water Program program.director-dwp@mass.gov

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