State of California
Household Water Supply Shortage Reporting Form
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
. Information submitted through this application can be viewed by the public and/or provided to local agencies.
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.
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.
Owner or renter of the property
Member of local agency organization
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.
Water Problem Information:
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?
Dry well (groundwater)
Low creek, stream, spring, or other surface water source
Please describe the water issue
Well is dry (no longer producing water)
Reduction in water pressure, lower flows.
Well is pumping sand, muddy water.
Well is catching air, have to wait to be able to pump.
Reduction in water quality
What is the primary use of this well or creek?
Combination of Household/Agriculture
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] Please provide location information about the water issue.
San Luis Obispo
State Level Sites
Provide Physical Well Location by: 1) Street Address 2) Latitude and Longitude, or 3) Crossroads; and Interactive Map
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
Yes, lowered the pump bowl
Yes, deepened the well
Yes, drilled replacement well.
No, trucking in water
No, getting water from our neighbors with a hose
No, on drilling wait list.
No, cannot afford to finance solutions.
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
Well Log Data (if known):
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. (
Do you have a well log or well completion report?
What is the depth to water in the well?
In feet, if known:
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
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)
No, it's pumping at the same rate
Yes, about a 10% reduction
Yes, about a 20-30% reduction
Yes, about a 30-40% reduction
It's no longer producing any water
Local Well ID (if known)
Site ID (if known)
Station Number (if known)
Helpful Resources for Homeowners:
County Offices of Emergency Services are the first responder during drought to provide what local resources are available
We encourage you to call your
Local County Emergency Services Office
Emergency Bottled Water/Hauled Water Programs
Individuals should contact Self-Help Enterprises who serves eligible households in Merced, Madera, Fresno, Tulare, Kings, and Kern counties.
Self-Help Enterprises, Emergency Services Program at (559) 802-1685 or by email at
English TTY: (800) 735-2929
Spanish TTY: (800) 855-3000
Main Self Help Enterprises Emergency Services Webpage
Self Help Enterprises Emergency Services
English & Spanish flyer
Tulare County Bottle Water Program
Community Water Center for more information
Central Coast Regional Bottled Water Program serving Santa Cruz, Monterey, San Benito, San Luis Obispo and Santa Barbara
Community Water Center via their Program webpage
Loans for Well Replacement for Households
Household Water Well System (HWWS) Loan Program for refurbishing, replacing or constructing a well by Rural Community Assistance Corporation
or (916) 447-2854
Funding for connecting abandoned or dry wells to other systems for unincorporated areas of counties and cities
Household residences should contact their city or county housing department (respectively) and ask about the availability of "Community Development Block Grant housing rehabilitation" funding
for more information about this
California Department of Housing and Community Development CDBG funding
Funding for Tribal Governments, Water Systems and Non-Profits for both Emergency water and well rehabilitation
Contact the State Water Resource Control Board about their
Urgent Drinking Water Project Funding
Find a well drilling/maintenance contractor
Well drillers can help lower well pumps, drill wells, clean well screens, and assess casings to allow for optimal well flow
Website to find well contractors
Find the local agency that will issue a permit for well rehabilitation or drilling a new well
To refurbish, replace or construct a well,
apply for a well permit from your local county
Contact your local groundwater sustainability agency
To learn more about groundwater management in your region, find your
Groundwater Sustainability Agency
Reported by Agency/Local Government/Housing Assistance Organization:
This section is only to be completed by a local agency official when preparing this form on behalf of a member of the public
Agency or Organization
e.g. USDA, DWR, OES, CDPH, HCD, Self Help Enterprises etc.
Use this space if there are planned actions or follow up steps to be taken with the caller.
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Last Modified: 10/08/2015