WATER RESOURES MAMAGEMENT AUTHORITY

Groundwater Unit

Name of Applicant:…………………………………………………… GPS Coordinates: E………………… S…………………..

1. Pollution type/source and minimum distance Elevation: Percentage
from water abstraction point (radius) Comment If yes

i. Pit latrine: minimum distance 30 meters >.75%

ii. Septic tank and soakaway: minimum distance 30 >.75%

meters
iii. Unprotected shallow well: minimum distance 30 <.75%
meters
iv. Waste disposal (formal or informal): minimum <.75%
distance 500 meters
v. Sewage effluent / lagoon / pond: minimum <.75%
distance 50 meters
vi. Animal pen/kraal: minimum distance 50 meters <.75%

vii. Farm stables and sheds: minimum distance 50 <.75%

meters
viii. Garages: minimum distance 30 meters <.75%

ix. Manure or composting materials application: >.75%

minimum distance 30 meters
x. Fuel storage: minimum distance 100 meters >.75%

xi. Pesticide or fertilizer storage: minimum distance >.75%

100 meters
xii. Parking lots, roads and railways: minimum <.75%
distance 50 meters
xiii. Dead animal burial or composting site: <.75%
minimum distance 100 meters
xiv. Cemeteries: minimum distance 500 meters >.75%

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2. Are there existing commercial boreholes within 250m: Yes No
3. Are there existing domestic boreholes within 30m: Yes No
If yes to 2 and/or 3 above, state how many:
4. Type of Aquifer and minimum distances between boreholes (m) Comment
i. Intergranular – porous or fractured sandstones: 50 meters
ii. Fractured basement/consolidated rocks: 50 meters
iii. Fissured deep weathered zone: 30 meters
iv. Cavity or karstic fractured limestone: 100 meters
v. Unconsolidated sediments (e.g., Aeolian Kalahari deposits): 200
meters
5. Water Quality parameters (to be done after the borehole becomes productive).
i.Temperature:……………………………………………………….. ii. Electronic Conductivity:………………………………….....
iii. pH:……………………………………………………………………. iv. Total Dissolved Solids:……………………………………….
v. Nitrates:……………………………………………………………… vii. Iron:………………………………………………………………….

Notes in Brief:…………………………………………………………………………………………………………………………………………………………..
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Inspected By

1. Name…………………………………………………………………… Date and Time ……………………………………………………

Signature……………………………………………………….

2. Name…………………………………………………………………… Date and Time ………………………………………………….

Signature……………………………………………………….

Inspected in the presence of:……………………………………………………………………. Signature.……………………………

Recommended / Not Recommended By:………………………………………………. Signature.………………………….

Verified By:……………………………………………………………………………………………. Signature.………………………….