FORMS: Bureau of Water

Agricultural Facilities

Form Name DHEC Form #
Burial Site Request - Daily & Mass Burial Site Request Form D-2622
Burial Site Guidance - Guidance document for dead animal & disposal site approval  
Request for a Preliminary Site Inspection - Preliminary Site Inspection Form D-2623
Notice of Intent to Construct an Agricultural Facility - Notice of Intent Form for the New Agricultural Facilities D-3579
Agricultural Animal Facilities (Other than Swine) - Standard Application Form for New or Expanding Agricultural Animal Facilities Other than Swine D-3580
New or Expanding Small Swine Facilities (500,000 lbs or less) - Standard Application Form for New or Expanding Small Swine Facilities (500,000 lbs or less) D-3577
New or Expanding Large Swine Facilities (500,001 lbs or more) - Standard Application Form for New or Expanding Large Swine Facilities (500,001 lbs or more) D-3578
Stacking Shed and/or Composter - Standard Application Form for Stacking Shed and/or Composter D-2512
Agricultural Manure Brokers - Standard Application Form for Agricultural Manure Brokers D-2514
Agricultural Manure Applicators - Standard Application Form for Agricultural Manure Applicators D-2510
Modifications (for existing facilities) - Standard Application Form for Agricultural Facilities Modifications (for existing facilities) D-2511
Agricultural Permit Transfer of Ownership or Operation - Standard Application Form for Agricultural Permit Transfer of Ownership or Operation D-2513
Integrator Registration Form - Request for Integrator Registration Form D-2516
Manure Balance Sheet - Manure Balance Sheet for Manure Brokers ------
Manure Transfer Agreement - Manure Transfer Agreement Form ------

Chuck Williams, Section Manager - (803) 898-3112

 

Dams

Form Name DHEC Form #
Application to Construct or Alter a Dam - Application to Construct or Alter a Dam Application to Construct or Alter a Dam
Surveillance, Emergency Notification, and Action Plan for S.C. Regulated Dams - Surveillance, Emergency Notification, and Action Plan for S.C. Regulated Dams D-2606
Notification Form for Ownership Change of South Carolina Regulated Dams D-2605

John McCain - (803) 898-8178

 

Drinking Water

Form Name DHEC Form #
Consumer Confidence Report (CCR) Certification Form -  No later than the date the system is required to distribute the report to its customers (no later than July 1st), each community water system shall mail a copy of the report (CCR) to the Department (no later than July 1st), followed within 3 months (October 1st) by a certification that the report has been distributed to customers, and that the information is correct and consistent with the compliance monitoring data either provided by or submitted to the Department. See an example CCR Certification Form. D-3999
Construction Permit Application - Drinking Water and/or Wastewater Facilities - This form must be completed as part of an application package submitted for DHEC approval of water and/or wastewater systems construction plans D-1970
Small Business Water System Construction Permit Application - For building a well system for small business (not federally-defined systems) D-1206
Water Line Extensions - General Construction Permit Application for Public Water Supply Systems - For utilities who design their own water line extensions and meet certain criteria. D-2507
Application for Transfer of Operating Permit for A Public Water System - Drinking water systems have operating permits that must be transferred (and a viability review completed) D-1329
Bacteriological Analysis Input Form - This form is used by all Community and Non-Transient Non-Community PWS to reports their monthly/quarterly bacteriological samples as well as their average Chlorine Residual. D-1974
Optimum Corrosion Control Treatment (OCCT) Recommendation - Desktop Evaluation Short Form for Small and Medium Public Water Systems - This form is used to describe a small or medium public water system after the system has exceeded a Lead & Copper Rule trigger value. The Department requires a water system that has exceeded a trigger value to complete an Optimum Corrosion Control Treatment study and this form is used to help determine if the proposed treatment will be effective at lowering lead and/or copper levels. D-2134
Optimum Corrosion Control Treatment - Documentation Flushing Records - This form is used to document water system flushing activities after a water system has proposed flushing as optimum treatment to lower Lead and Copper values. D-2515
Controlled Fluoridation Monthly Report - This form is submitted to the Department monthly by drinking water systems that add fluoride to the water. D-2613
Lead and Copper Monitoring Report Form Justification for Change of Sample Site - Form used if a system needs to change a lead and copper tap sampling site, proper justification for the change must be provided. D-3023
Lead and Copper Monitoring Reporting Form Analytical Results for Lead and Copper - Form to submit analytical results from sampling. D-3024
 Lead and Copper Monitoring Reporting Form Analytical Results for Water Quality Parameter Monitoring - Form to submit analytical results for water quality parameter monitoring. D-3025
Lead and Copper Monitoring Report Form for Non-Transient Non-Community Water Systems - Form to submit analytical results non-transient non-community water systems. D-3162
Public Education on Lead in Drinking Water - Form for public water system to conduct a public education (PE) program on lead in drinking water. D-3997

Rich Welch - (803) 898-3546 (Plants/Treatment)
Bridget Clarke - (803) 898-4239 (Lines)

 

Groundwater Monitoring

Form Name DHEC Form #
Monitoring Well Application - Use to request approval from DHEC to install groundwater monitoring wells at a site D-3736
Groundwater Monitoring Report - Use to report groundwater monitoring data to DHEC if such data are required by a wastewater or sludge disposal permit D-2110

Dusty Leypoldt - (803) 898-4312

 

(Groundwater) Underground Injection Control

Form Name DHEC Form #
Underground Injection Control Permit Application - Permit application for the emplacment of fluids into the subsurface through a well. D-2502
Guidance Document for Underground Injection Control Permit - Permit guide for Underground Injection Control ------

Bruce Crawford - (803) 898-4177

 

Groundwater Use and Capacity Use

Form Name DHEC Form #
Groundwater Withdrawal Permit Application - Applicable for groundwater withdrawals exceeding 3 million gallons in any given month in a Designated Capacity Use Area D-2504
Notice Of Intent (New well construction) and Directions - Applicable for groundwater withdrawals exceeding 3 million gallons in any given month in the Coastal Plain Region outside of a Designated Capacity Use Area D-3724
Water Use Registration - Applicable for groundwater withdrawals exceeding 3 million gallons in any given month in the Piedmont Region D-3764
Capacity Use Program Permitting - Permitting guide for groundwater withdrawal in Designated Capacity Use Areas ------

Alex Butler - (803) 898-3575
Josh Zodarecky - (803) 898-3559

 

Surface Water Withdrawal

Form Name DHEC Form #
Surface Water Withdrawal Permit Application - D-2755
Agricultural Surface Water Withdrawal Registration Application - D-2756
Application to Modify Existing Agricultural Surface Water Withdrawal Registration - D-2763

Leigh Anne Monroe - (803) 898-2415

 

Navigable Waters

Form Name DHEC Form #
Permit Application for Construction in Navigable Waters (Individual, General Permits) - Application for construction of any structure in, over or under navigable waters of the state of South Carolina D-2065

Chuck Hightower - (803) 898-0369
Heather Preston - (803) 898-3105

 

Pesticides - NPDES

Form Name DHEC Form #
Notice of Intent (NOI): NPDES General Permit for Discharges from the Application of Pesticides (SCG160000) - For coverage to spray for mosquitoes, control aquatic weeds, manage rights-of-way, etc D-2732

Shawn Clarke - (803) 898-3544

 

Private Well

Form Name DHEC Form #
Notice of Intent - Well location information submitted prior to installation of an individual residential well or irrigation well D-3647
Water Well Record Form - Well construction information submitted by well driller after well is completed D-1903

Alex Butler - (803) 898-3575
Greg Withycombe - (803) 898-3232

 

Recreational Waters

Form Name DHEC Form #
Swimming Pool Application to Construct a Recreational Water Facility - To build a public swimming pool, water park, etc. D-2501
Swimming Pool Final Inspection Checklist - Items needed prior to requesting an approval to place a pool into operation following construction. D-1931
Swimming Pool Change Order Request Form - Modifications to public pools that don�t require a construction permit. D-3627
Swimming Pool Facility Information Sheet - The purpose of this form is to allow the Department to maintain accurate information on facility billing addresses and site contact information including their Pool Operator of Record. D-3441
Swimming Pool Incident Report - This form serves as the required written record when notifying the Department of a serious incident involving a permitted aquatic facility. D-3785
Swimming Pool Inspection Report - This form is used by summer inspectors and recreational water mangers when inspecting commercial swimming pools (types A, B, C, D, E, F and G) in SC. Pool operators may use this as guidance. D-1928
Natural Recreational Facility Application for Initial Certification - Required for the initial permitting of a natural swimming area. Submitted in conjunction with the five initial water quality samples determining the fitness of the location of the proposed swimming beach. D-3821
Natural Recreational Facility Application for Annual Permit to Operate - This form is required annually and is used to update facility contact information and to notify the Department of the owner's intent to operate for the coming season. D-1926
Bacteriological Analysis Input Form - Submitted to the Department by the owner/operator of a natural swimming area, or their agent, and enumerates the Fecal Coliform sample results for the previous sample period. Required approximately every two weeks during the swimming season. D-3631

Luke Abel - (803) 898-4255

 

State Revolving Fund

Form Name DHEC Form #
Drinking Water Project Questionnaire - Used to submit a potential project for consideration of funding through the Drinking Water State Revolving Loan Fund (DWSRF) for eligible drinking water construction/activities. D-3463
Wastewater Project Questionnaire - Used to submit a potential project for consideration of funding through the Clean Water State Revolving Loan Fund (CWSRF) for eligible wastewater, stormwater or 319 nonpoint source construction/activities. D-3561
Draw Request Form - Used to request payment from the State Revolving Loan Fund. D-3585
Official Designation and Signature Form - Used to specify which project representatives are to represent the project sponsor in all matters pertaining to administration of the SRF loan. D-3586
Monthly Construction Inspection Report - Used to document the progress of an SRF project under construction. D-3587
Schedule for Construction - Schedule for Construction Used to document the expected schedule of milestones from project start to completion. D-3588
Project Construction Summary - Check sheet that assists sponsors in supplying the required information and documents to the SRF Section. D-3589
Certification Regarding Debarment, Suspension and Other Responsibility Matters - Used to certify that possible participants are not debarred, suspended or otherwise excluded from participation in Federal assistance programs. D-3590
Prime Contractor's Subagreement Certification - Used to certify whether or not a contractor plans to use subcontractors to perform work for any part of the project. D-3591
Certification by Proposed Prime or Subcontractor Regarding Equal Employment Opportunity - For any bidder or prospective contractor/subcontractor to certify whether they have participated and been compliant in any previous contract subject to the equal opportunity clause. D-3592
SRF - Certification Regarding Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 - Used to certify compliance with the Uniform Relocation Assistance And Real Property Act of 1970, regarding property acquisition. D-3594
Preaward Compliance Review Report for All Applicants Requesting Federal Financial Assistance - Used to document the compliance of recipients of Federal financial assistance from the EPA regarding various Federal statutes/requirements EPA 4700-4
MBE/WBE Utilization Under Federal Grants, Cooperative Agreements, and Interagency Agreements - Completed by recipients of Federal assistance regarding to report the accomplishment of minority/women business enterprises (MBE/WBE). EPA 5700-52A
Project Sponsor's "American Iron and Steel" Certification for Direct Equipment/Material Purchases - Used to certify that all iron and steel products used in an SRF project are produced in the US, unless granted a waiver. D-0962
Bidder's "American Iron and Steel" Certification - Used to certify that all iron and steel products used in an SRF project are produced in the US, unless granted a waiver. D-2556
Project Sponsor's "American Iron and Steel" Certification - Used to certify that the project is in compliance with American Iron and Steel requirements during project construction. D-2558

Lynne I. Lasalle - (803) 898-4395
Charles Gorman - (803) 898-3993

 

Stormwater - NPDES

Form Name DHEC Form #
Stormwater Notice of Intent - For Coverage Under the Stormwater NPDES General Permit for Discharges Associated with Industrial Activity Except Construction D-2611
The Notification Form for Sites Disturbing Less Than 1-Acre. This form is for use on projects located outside of the eight coastal counties (Beaufort, Berkeley, Charleston, Colleton, Dorchester, Georgetown, Horry, and Jasper) and that are NOT part of a larger common plan for development or sale. D-2628
Stormwater Notice of Termination - For Terminating Coverage Under the Stormwater NPDES General Permit for Discharges Associated with Industrial Activity. D-2609
Stormwater Notice of Termination - For Terminating Coverage Under the Stormwater NPDES General Permit for Discharges Associated with Construction Activity. D-2610
Notice of Intent (NOI) for Coverage(s) of Primary Permittees Under South Carolina NPDES General Permit for Stormwater Discharges From Construction Activities - Revision to DHEC Form 2617 for coverage under the new 2012 Stormwater NPDES General Permit D-2617
Consolidated Permits Program - Application Form 1 - This is EPA's Application Form 1. It contains general information about the applicant and facility. This form must accompany the individual NPDES permit application - Form 2f. EPA 3510
No Exposure Certification for Exclusions from NPDES Stormwater Permitting - This form is to be used if industrial materials or activities are not exposed to stormwater, this form may be used to request an exemption. D-2616
Erosion Prevention and Sediment Control Monthly Report - This form may be used to meet the monthly reporting requirements found in the NPDES Construction General Permit. D-1356
Individual Lot Notice of Intent - For Coverage of Secondary Permittees Within Residential Subdivisions Under the new 2012 Stormwater NPDES General Permit D-0432
Annual Blanket Notice of Intent - For Statewide Coverage of Utility Providers Within Common Developments Under the new 2012 Stormwater NPDES General Permit D-0433

Isiah Glover - (803) 898-4005

 

Wastewater - Compliance

Form Name DHEC Form #
Sewer System Overflow or Pump Station Failure Report Form Form is to be used for reporting a sewer system overflow or pump station failure. D-3685
Satellite Sewer System Owner Notification Form - general permit coverage for operation of a sewer collection system where the final treatment for wastewater is by another entity D-2614

Dale Stoudemire - (803) 898-4209

 

Wastewater - Construction

Form Name DHEC Form #
General Construction Permit Application - The initial application for a public entity to be considered for general permit coverage. D-1794
General Construction Permit NOI - The form used to notify DHEC of a proposed construction project, once a public entity has been approved for general permit coverage. D-1793
Construction Permit Application - Water and/or Wastewater Facilities - For building water and sewer lines, treatment systems, wells, etc. D-1970
Industrial Wastewater Facility Closure Form D-1795

Bridget Clarke - (803) 898-4239 (Lines)
Kyle Maurer - (803) 898-4228 (Facilities)

 

Wastewater - ND Permits

Form Name DHEC Form #
No Discharge or ND Permit Application - The ND Permit Application is used as part of a Preliminary Engineering Report (PER) submittal for New, Expanding, and Renewals of Wastewater Treatment Plants with Land Disposal of Wastewater or Sludge. Sludge Supplement must accompany NPDES and ND Forms. ----
Location Supplement for NPDES and ND Permit Applications - To confirm the location of the proposed discharge ----
Sludge Disposal Supplement for NPDES and ND Permit Applications - To provide details about sludge management proposed from the applicable wastewater treatment system. ----
Notice of Intent (NOI) - Land Application (No Discharge) Associated with Nonmetallic Mineral Mining Facilities - ND General Permit #NDG730000 - General permit coverage for mining operations not involving metals (e.g. fill dirt mining) D-3239

Kyle Maurer - (803) 898-4228 (Domestic)
Crystal Rippy - (803) 898-3964 (Industrial)
Bureau of Water - Phone: (803) 898-4300 Fax: (803) 898-3795.

 

Wastewater - NPDES

Form Name DHEC Form #
Notice of Intent (NOI) - Discharges Associated with Hydroelectric Generating Facilities - NPDES General Permit #SCG360000 D-2239
Notice of Intent (NOI) - Potable Water Treatment Plants (SCG646000) - General permit coverage for discharges from water treatment systems D-1813
Notice of Intent (NOI) - NPDES General Permit for Bulk Petroleum Facility Discharges SCG340000 - General permit coverage for discharges associated with bulk petroleum facilities D-2624
Notice of Intent (NOI) - Discharges Associated with Nonmetallic Mineral Mining Facilities - NPDES General Permit #SCG730000 - General permit coverage for mining operations not involving metals (e.g., sand and gravel mining) D-3559
Notice of Intent (NOI) - Hydrostatic Test Water: Discharges From New and Used Oil and Gas Lines and Tanks - NPDES General Permit #SCG670000 - General permit coverage for testing for these lines and tanks D-3729
Notice of Intent (NOI) - Utility Water Discharges - NPDES General Permit #SCG250000 - General permit coverage for a variety of utility water discharges within a certain threshold D-3632
Notice of Intent (NOI) - Vehicle Wash Water: Discharges From Vehicle Wash Water Discharges - NPDES General Permit #SCG750000 D-3756

Consolidated Permits Program - Application Form 1 - General Information - This is EPA's Application Form 1. It contains general information about the applicant and facility. This form must accompany the NPDES permit application.

EPA 3510

Consolidated Permits Program - Application Form 2C - Wastewater Discharge Information - EPA Form 2C is used by existing industrial facilities when reapplying for an NPDES permit. Instructions are included. This form must be accompanied by EPA Form 1, the Location Supplement, and the Sludge Supplement.
Location Supplement for NPDES and ND Permit Applications
Sludge Disposal Supplement for NPDES and ND Permit Applications
Mixing Zone Supplement

EPA 3510-2C

Application Form 2D - New Dischargers and New Sources: Application to Discharge Process Wastewater - EPA Form 2D is used by industrial facilities when applying for new discharges or new sources. Instructions are included. This form must be accompanied by EPA Form 1, the Antidegradation Supplement, the Location Supplement, and the Sludge Supplement.
Location Supplement for NPDES and ND Permit Applications
Sludge Disposal Supplement for NPDES and ND Permit Applications
Mixing Zone Supplement

EPA 3510-2D

Application Form 2E - Facilities Which Do Not Discharge Process Wastewater - EPA Form 2E is used by facilities which do not discharge process wastewater. Instructions are included.This form must be accompanied by EPA Form 1, the Location Supplement, and the Sludge Supplement.
Location Supplement for NPDES and ND Permit Applications
Sludge Disposal Supplement for NPDES and ND Permit Applications
Mixing Zone Supplement

EPA 3510-2E
Antidegradation Supplement for NPDES Permit Applications - The Antidegradation Supplement must be filed when an NPDES application is for a new or expanding discharge (including new/increased loadings). D-3590

EPA Form 2A is used by municipal facilities when applying for new discharges or new sources. Instructions are included. This form must be accompanied by the Antidegradation Supplement, the Location Supplement, and EPA Form 2S.
Location Supplement for NPDES and ND Permit Applications
Sludge Disposal Supplement for NPDES and ND Permit Applications
Mixing Zone Supplement
Part D-Excel spreadsheet application data

EPA 3510-2A
Sludge Loading Worksheet D-0874

Form 2S Instructions

EPA Form 2S - used by municipal facilities when applying for new discharges or new sources. Instructions are included. This form must be accompanied by the Form 2A and the Location Supplement.
Location Supplement for NPDES and ND Permit Applications

EPA 3510-2S

Kyle Maurer - (803) 898-4228 (Domestic)
Crystal Rippy - (803) 898-3964 (Industrial)

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