Thank you in advance for your time.
To better serve and address you, please help us identify who you represent.
This section is only to be completed by a local agency official when preparing this form on behalf of a member of the public
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.
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*.
Please provide location information about the water issue. Provide at least one physical well location by: Full Address, Parcel Number (APN), Nearest Street Intersection,
Latitude & Longitude. Location information is useful to connect you to your local entities that may have
Use the interactive map to pinpoint your latitude and longitude coordinates.
If left blank, the latitude and longitude will be geocoded with other filled location information.
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.