What is this form?
General Information and Instructions

    How is this information going to be used?
  • This information is intended to inform state, county and local agencies on drought impacts on household water supplies and should not be construed as an application for local, state or federal assistance. Individuals interested in assistance can access available local and state resources on the Resources page. Information submitted through this application can be viewed by the public and/or provided to local agencies.

    Form Components:
  • Contact Information (Who is having the problem?)
  • Water Problem Information (What is the problem?)
  • Water Problem Location (Where is the problem?)
  • Available Financial Resources (Information to share, if interested.)
  • Well Log Data (If known)
  • Agency/Local Government Information (Required for Agency users only)

Thank you in advance for your time.


Required
Who do you represent?
What is this?
To better serve and address you, please help us identify who you represent.
Please choose the appropriate option to identify who you are representing.
Contact Information:
What is this form?
Please enter the name, phone number, and email address for the owner or renter of the property experiencing a disruption in water supply. By leaving a name and contact information, someone may be able to follow up if and when new resources become available.
Name
Phone Number
Email
Water Problem Information:
[Required section]:
Please make every effort to share information about the water supply issue so the State can track the different types of problems that are occurring. *The most important information in this form is the location of the water problem in the next section*.
What type of water shortage are you facing?
Please describe the water issue
What is the primary use of this well or creek?
If household use, what kind of household is the well supporting?
(skip if this if well is primarily used for Agriculture/Irrigation)
How many people are in the household?
(A number from 1 to 999)


Approx. date problem started
Additional notes about water problem

Water Problem Location Information

[Required section]:
[Required section] Please provide location information about the water issue.
County
Provide Physical Well Location by: 1) Street Address 2) Latitude and Longitude, or 3) Crossroads; and Interactive Map

Street Address
City
Zip Code
OR Parcel Number (APN) [if known]
Parcel on which well is located; please do not include dashes.
OR provide names of streets at nearest road intersection
If APN or physical address is unknown, use either crossroads or Lat/Long point.
OR Latitude & longitude
Use map to pinpoint your latitude and longitude coordinates.
Click on the map to enable interactive map
What is the total depth of your well?
Was the problem resolved?
Please choose the answer which describes how
If you tried a different solution and were not successful, please describe the steps you took below
If your well was fixed, please note the approximate cost of repairs
Additional Information
Well Log Data (if known):
[Optional section]:
This section provides information about the construction of groundwater well that is used for water supply. Well logs are also known as well completion reports. These are typically completed by the well driller at the time the well is installed. It provides information about the construction (depth, screening, etc) of a well. If you do not have it, it can be requested from your county Depart. of Environmental Health, other well-permitting entity or from the Department of Water Resources. (https://water.ca.gov/Programs/Groundwater-Management/Wells/Well-Completion-Reports)
Do you have a well log or well completion report?
  • Yes
  • No
What is the depth to water in the well?
In feet, if known:
Date Measured
Was the measurement taken with the pump was running or running within the last 15 minutes?
i.e. not during or just after the well was being pumped
  • Yes
  • No
Pumping Information
At what rate does the well normally produce water? (In gallons per minute, or indicate units)
Has the pumping rate been reduced? If yes, about how much?
(Please indicate the percentage of change in gallons per minute produced)






Helpful Resources for Homeowners: