Data Request Form

MN Source Water Protection Tracking Program

* = Required

Organization requesting data access*

1. OrganizationEnter Organization
2. None

Please answer question Requesting data access before continuing.

Please fill in the text box next to the selected choice in question Requesting data access.

Name and contact information of individual representatives

Name*

Address

City

State

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Email*

Phone

Date needed

Format: mm/dd/yyyy

Please answer question Contact information (Name*) before continuing.

Your answer to question Contact information (Zip code) must be a valid ZIP Code.

Please answer question Contact information (Email*) before continuing.

Your answer to question Contact information (Email*) must be a valid email address.

Your answer to question Contact information (Phone) must be a valid U.S. or Canadian Phone Number.

Your answer to question Contact information (Date needed) must be a valid date.

Select all data below you are asking for and complete additional questions for each selection before submitting this form.

What data are you asking for?*
If you don't know, choose "Other" and complete additional questions.

1. 1. Full access to Public Water Supply Information in CWI
2. 2. Emergency Response Areas (ERAs)
3. 3. Inner Wellhead Management Areas (IWMZ)
4. 4. Spill Management Areas (SMAs)
5. 5. Surface water Intake Locations
6. 6. Other

Please answer question Data asking for before continuing.

Please select at least 1 choices for question Data asking for.

Complete additional questions for Full access to Public Water Supply Information in CWI

a. Please describe how the data will be used.*

Please answer question a. Describe how used before continuing.

b. Are you planning on redistributing this data for commercial purposes?*

1. Yes
2. No

Please answer question b. Redistributing this data before continuing.

c. What mechanisms, processes, or controls do you have to secure and manage the data? (e.g., password protected, controlled access network, limited access)*

Please answer question c. How to manage data before continuing.

d. Acknowledgement and affirmation of data use restrictions*

• Information will be secured in a manner to preclude unauthorized access.
• Information will be used for internal business purposes or environmental assessment only; other uses are not authorized.
• Redistribution of information in any format is not permitted.
• Display of information on the Internet, or in publications or in public displays is not permitted without written permission.
• Information may be referenced in publications in summary form.
  
  

1. By selecting here, I understand and agree to the use restrictions.

Please answer question d. Acknowledgement before continuing.

Complete additional questions for Emergency Response Areas (ERAs)

a. Please describe the information you are interested in obtaining (please be as specific as possible).*

Please answer question a. Information you are interested in before continuing.

b. Describe the data format you would like (e.g., .csv, .dbf, .shp, .xlsx, etc).*

Format

Please answer question b. Data format (Format) before continuing.

c. Describe the specific data criteria of the data request, including geographic extent.*

Please answer question c. Specific data criteria before continuing.

d. Please describe how the data will be used.*

Please answer question d. Describe how used before continuing.

e. Are you planning on redistributing this data for commercial purposes?*

1. Yes
2. No

Please answer question e. Redistributing this data before continuing.

f. What mechanisms, processes, or controls do you have to secure and manage the data? (e.g., password protected, controlled access network, limited access)*

Please answer question f. How to manage data before continuing.

g. Acknowledgement and affirmation of data use restrictions*

• Information will be secured in a manner to preclude unauthorized access.
• Information will be used for internal business purposes or environmental assessment only; other uses are not authorized.
• Redistribution of information in any format is not permitted.
• Display of information on the Internet, or in publications or in public displays is not permitted without written permission.
• Information may be referenced in publications in summary form.
  
  

1. By selecting here, I understand and agree to the use restrictions.

Please answer question g. Acknowledgement before continuing.

Complete additional questions for Inner Wellhead Management Areas (IWMZ)

a. Please describe the information you are interested in obtaining (please be as specific as possible).*

Please answer question a. Information you are interested in before continuing.

b. Describe the data format you would like (e.g., .csv, .dbf, .shp, .xlsx, etc).*

Format

Please answer question b. Data format (Format) before continuing.

c. Describe the specific data criteria of the data request, including geographic extent.*

Please answer question c. Specific data criteria before continuing.

d. Please describe how the data will be used.*

Please answer question d. Describe how used before continuing.

e. Are you planning on redistributing this data for commercial purposes?*

1. Yes
2. No

Please answer question e. Redistributing this date before continuing.

f. What mechanisms, processes, or controls do you have to secure and manage the data? (e.g., password protected, controlled access network, limited access)*

Please answer question f. How to manage data before continuing.

g. Acknowledgement and affirmation of data use restrictions*

• Information will be secured in a manner to preclude unauthorized access.
• Information will be used for internal business purposes or environmental assessment only; other uses are not authorized.
• Redistribution of information in any format is not permitted.
• Display of information on the Internet, or in publications or in public displays is not permitted without written permission.
• Information may be referenced in publications in summary form.
  
  

1. By selecting here, I understand and agree to the use restrictions.

Please answer question g. Acknowledgement before continuing.

Complete additional questions for Spill Management Areas (SMA)

a. Please describe the information you are interested in obtaining (please be as specific as possible).*

Please answer question a. Information you are interested in before continuing.

b. Describe the data format you would like (e.g., .csv, .dbf, .shp, .xlsx, etc).*

Format

Please answer question b. Data format (Format) before continuing.

c. Describe the specific data criteria of the data request, including geographic extent.*

Please answer question c. Specific data criteria before continuing.

d. Please describe how the data will be used.*

Please answer question d. Describe how used before continuing.

e. Are you planning on redistributing this data for commercial purposes?*

1. Yes
2. No

Please answer question e. Redistributing this data before continuing.

f. What mechanisms, processes, or controls do you have to secure and manage the data? (e.g., password protected, controlled access network, limited access)*

Please answer question f. How to manage date before continuing.

g. Acknowledgement and affirmation of data use restrictions*

• Information will be secured in a manner to preclude unauthorized access.
• Information will be used for internal business purposes or environmental assessment only; other uses are not authorized.
• Redistribution of information in any format is not permitted.
• Display of information on the Internet, or in publications or in public displays is not permitted without written permission.
• Information may be referenced in publications in summary form.
  
  

1. By selecting here, I understand and agree to the use restrictions.

Please answer question g. Acknowledgement before continuing.

Complete additional questions for Surface water Intake Locations

a. Please describe the information you are interested in obtaining (please be as specific as possible).*

Please answer question a. Information you are interested in before continuing.

b. Describe the data format you would like (e.g., .csv, .dbf, .shp, .xlsx, etc).*

Format

Please answer question b. Data format (Format) before continuing.

c. Describe the specific data criteria of the data request, including geographic extent.*

Please answer question c. Specific data criteria before continuing.

d. Please describe how the data will be used.*

Please answer question d. Describe how used before continuing.

e. Are you planning on redistributing this data for commercial purposes?*

1. Yes
2. No

Please answer question e. Redistributing this data before continuing.

f. What mechanisms, processes, or controls do you have to secure and manage the data? (e.g., password protected, controlled access network, limited access)*

Please answer question f. Manage the data before continuing.

g. Acknowledgement and affirmation of data use restrictions*

• Information will be secured in a manner to preclude unauthorized access.
• Information will be used for internal business purposes or environmental assessment only; other uses are not authorized.
• Redistribution of information in any format is not permitted.
• Display of information on the Internet, or in publications or in public displays is not permitted without written permission.
• Information may be referenced in publications in summary form.
  
  

1. By selecting here, I understand and agree to the use restrictions.

Please answer question g. Acknowledgement before continuing.

Complete additional questions for Other Data

a. Please describe the information you are interested in obtaining (please be as specific as possible).*

Please answer question a. Information you are interested in before continuing.

b. Describe the data format you would like (e.g., .csv, .dbf, .shp, .xlsx, etc).*

Format

Please answer question b. Data format (Format) before continuing.

c. Describe the specific data criteria of the data request, including geographic requirements and years of interest.

d. Describe additional summary information that would be useful to you.

e. Please describe how the data will be used.*

Please answer question e. How data will be used before continuing.

f. Are you planning on redistributing this data for commercial purposes?*

1. Yes
2. No

Please answer question f. Redistributing this data before continuing.