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Document Sample
Part A: General
Answer Item Item Discription
A Water System
A1 Name (type name in cell A7)
A2 State or EPA Identification Number
B Type of Public Water Supply System
B1 Community water system
B2 Non-transient, non-community system
B3 Transient, non-community
C Population Served
D Water Demands or Water Use
D1 Average daily water demand (annual basis) (gal per day)
D2 Maximum daily water demand (gal per day)
D3 Information on water demands not available
E Type of Water Source or Sources
E1 Treated water purchased from another entity
E2 Untreated water purchased from another entity
E3 Surface Water
E3 a Number of sources that are diverted from river or stream
E3 b Number of sources that are drawn from a lake or impoundment
E4 Ground Water
E4 a Number of sources that are wells
E4 b Number of sources that are drilled, horizontal well collectors
E4 c Number of sources that are springs
E4 d Number of sources that are infiltration galleries
F Type of Water Treatment
F1 No treatment or disinfection provided for any source
F2 Surface water supply – disinfection/corrosion control only
F2 a Number of stream or river sources
F2 b Number of lake or impoundment sources
F3 Surface water supply – filtration/disinfection/corrosion control
F3 a Number of stream or river sources
F3 b Number of lake or impoundment sources
F4 Ground water supply – disinfection/corrosion control only
F4 a Number of wells
F4 b Number of drilled, horizontal well collectors
F4 c Number of springs
F4 d Number of infiltration galleries (not associated with a spring)
F5 Ground water supply – other treatment types
F5 a Number of wells
F5 b Number of drilled, horizontal well collectors
F5 c Number of springs
F5 d Number of infiltration galleries (not associated with a spring)
G Pumps and Pump Stations
G1 Number of raw water pumping stations for a surface water supply
G2 Treated water pumping:
G2 a Number of surface water supply pump stations
G2 b Number of spring water supply pump stations
G2 c Number of horizontal collector well pump stations
G2 d Number of infiltration gallery pump stations
G3 Number of ground water pump stations at wells
G4 Number of distribution system booster pump stations
H Water Storage Tanks
H1 System has no storage tanks, including hydropneumatic tanks
H2 Number of hydropneumatic (pressure) tanks
H3 Number of storage tanks (steel, concrete, fiberglass, etc.)
I Raw or treated water transmission pipeline
I1 Water system has raw water transmission pipelines
I1 a Number of raw water transmission pipelines
I1 b Approximate feet or miles of raw water transmission pipeline
I1 b 1) Feet of pipe
I1 b 2) Miles of pipe
I2 Water system has treated water transmission pipelines
I2 a Number of treated water transmission pipelines
I2 b Approximate feet or miles of treated water transmission pipeline
I2 b 1) Feet of pipe
I2 b 2) Miles of pipe
J Distribution system
J1 This water system does not have a distribution system
J2 Water system has a distribution system
J3 Approximate feet or miles of pipe in distribution system
J3 a Feet of pipe
J3 b Miles of pipe
Water System Summary
Water System Name:
This water system has been classified as Select a water system type
Water system serves a population of 25
Water system demands:
Average day demand = 0 gal/day
Maximum day demand = 0 gal/day
Water system has the following number of sources:
0 Diversions from streams or rivers
0 Diversions from lakes or impoundments
0 Wells
0 Drilled, horizontal well collectors
0 Springs
0 Infiltration galleries not associated with springs
Water system has the following number and type of treatment facilities:
0 Filtration/disinfection/corrosion treatment for a stream or river water supply
0 Filtration/disinfection/corrosion treatment for a lake or impoundment water supply
0 Disinfection/corrosion treatment only for a stream or river water supply
0 Disinfection/corrosion treatment only for a lake or impoundment water supply
0 Facilities that provide more than just disinfection of ground water from a well
0 Facilities that provide more than just disinfection of ground water from a drilled, horizontal well collector
0 Facilities that provide more than just disinfection of ground water from a spring
0 Facilities that provide more than just disinfection of ground water from an infiltration gallery
0 Disinfection/corrosion treatment only for well supply
0 Disinfection/corrosion treatment only for horizontal well collector supply
0 Disinfection/corrosion treatment only for spring supply
0 Disinfection/corrosion treatment only for infiltration gallery supply
Water system has the following number of pump stations:
0 Raw or untreated water pump stations for a surface water supply
0 Treated surface water pump stations
0 Treated spring water pump stations
0 Pump stations for horizontal well collector systems
0 Pump stations for infiltration galleries
0 Pump stations at wells
0 Distribution system booster pump stations
Water system has the following number and type of storage tanks
0 Hydropneumatic tanks
0 Concrete, steel, fiberglass, or other type
Water system has the following number and lengths of transmission pipelines
0 Number of raw, untreated water pipelines
0 Feet of treated water transmission pipelines
0 Number of treated, potable water transmission pipelines
0 Feet of treated water transmission pipelines
0 Feet of distribution system pipe
Based on the answers to Part A, the following Survey Sheets will be required:
# Copies Survey Sheet Name
Here are the steps you will follow to complete the Microbial Risk (MR) Toolbox:
Answer all questions in worksheet Part_A
(see "Introduction (Part A)" tutorial in MR Assessment Guide)
Print the type and number of Survey Sheets required
(see "Print Survey Sheets" tutorial in MR Assessment Guide)
Complete the Survey Sheets for each water system category
(see Units 2 through 6 of the MR Assessment Guide for additional information)
Enter data from the Survey Sheets into the Ranking Tool
(see "Introduction (Part A)" tutorial and Unit 1 of the MR Assessment Guide)
View and print the results
(see Unit 7 of the MR Assessment Guide)
View and print the comments
(see Unit 7 of the MR Assessment Guide)
No. SW Sources No. GW Sources
0 0
No. Storage
No. Pump Sta. Tanks
0 0
ntal well collector
No. Purchased No. Purchased Survey Survey
Untreated SourceTreated Source ID Name
0 0 BI B.I. – Water Source: Surface Water–Stream or River
No. Transmission BII B.II . – Water Source: Lake or Impoundment
Pipelines BIII B.III. – Water Source: Ground Water–Wells (includes Drilled, Horizontal W
0 BIV B.IV.– Water Source: Ground Water–Springs (includes Infiltration Galleri
CI C.I. – Surface Water Supply: Disinfection/Corrosion Control Treatment O
CII C.II. – Surface Water Supply: Filtration/Disinfection/Corrosion Control Tr
CIII C.III. – Ground Water Supply: Disinfection/Corrosion Control Treatment O
CIV C.IV.– Ground Water Supply: Other Treatment Types
DI D.I. – Pumping Facilities
DII D.II. – Storage
EI E.I. – Transmission Pipelines
EII E.II. – Distribution System
F F. – Water Quality Monitoring
Stream or River
Wells (includes Drilled, Horizontal Well Collectors)
Springs (includes Infiltration Galleries)
ion/Corrosion Control Treatment Only
n/Disinfection/Corrosion Control Treatment
tion/Corrosion Control Treatment Only
atment Types
Part B: W ater Source
I. Surface W ater - Stream or River I. Surface W ater - Stream or River
No. 1 No. 1
Answer Item Item Description Comments –
1 General Current Sum of % for All
1a Stream or river source No. Water Sources= 0.0
1b Percent of annual supply (Final value should equal 100)
2 Source W ater Assessment
2a Completed
2b In-progress
2c Not yet begun
3 Source W ater Protection Program
3a In-place and followed
3b Completed, not implemented
3c Under development
3d Not yet begun
4 Management of land use and activities
4a Not sure of agency that manages land use
4b Manage some land
4c Local, State or Federal agency manages land
4d Percent of land managed by water system
4e Percent of land managed by Local, State and Federal agencies
4f Watershed too large or complex to manage
4f 1) Yes, too large or complex
4f 2) No, not too large or complex
4g Could a program be developed and implemented
4g 1) Yes
4g 2) No
5 Native and domestic animals in watershed
5a No domestic animal grazing
5b No domestic animal confinement
5c Yes, domestic animal grazing or confinement with stream access
5d Yes, grazing or confinement with restricted stream access
5e Yes, domestic animal grazing or confinement within 400 feet of stream
5f Native animals
5f 1) Few native animals
5f 2) Moderate to large populations of native animals
6 Human access / activities within watershed
6a All human access to watershed is controlled
6b Hiking, camping, picnicking, fishing or hunting
6c Snowmobiling or skiing
6d Boating
6e Swimming
6f Logging
6g Mining
7 Upstream wastewater discharges
7a Not sure if they occur
7b No known discharges occur
7c Treated municipal, no CSOs
7d Treated municipal, CSOs can occur
7e Treated industrial/commercial
7f Septic tank/drainfield within 700 feet of streams, less than 10 miles upstream
7g 1) Yes, discharges closer than 10 miles upstream of intake
7g 2) No, greater than 10 miles upstream of intake
8 Upstream stormwater discharges/runoff
8a Not sure if they occur
8b Runoff from domestic animal confinement areas < 700 feet from stream
8c Urban / Suburban stormwater runoff occurs
8d Runoff from land receiving wastes that are < 700 feet from stream
8e 1) Yes, runoff occurs less than 10 miles upstream of intake
8e 2) No, greater than 10 miles upstream of intake
9 Surface water intake structures
9a Small opening Intake screen
9b Coarse bar rack for intake screen
9c 1) Security fence and locked gate restrict access
9c 2) Livestock fence around site, only
9c 3) Posted
9c 4) None of the above, no restrictions to access
9d 1) Yes, modifying intake could result in higher quality water
9d 2) No, modifying intake would not improve water quality
10 Known source of microbial contamination
10a Yes
10b No
11 Filtration waiver
11a Yes, water system has filtration waiver for this source
11b No filtration waiver
12 Does this water source receive any form of treatment, including disinfection?
12a Yes
12b No
Part B: W ater Source
I. Surface W ater - Stream or River Source I. Surface W ater - Stream or River Source
No. 2 No. 2
Answer Item Item Description Comments –
1 General Current Sum of % for All
1a Stream or river source No. Water Sources= 0.0
1b Percent of annual supply (Final value should equal 100)
2 Source W ater Assessment
2a Completed
2b In-progress
2c Not yet begun
3 Source W ater Protection Program
3a In-place and followed
3b Completed, not implemented
3c Under development
3d Not yet begun
4 Management of land use and activities
4a Not sure of agency that manages land use
4b Manage some land
4c Local, State or Federal agency manages land
4d Percent of land managed by water system
4e Percent of land managed by Local, State and Federal agencies
4f Watershed too large or complex to manage
4f 1) Yes, too large or complex
4f 2) No, not too large or complex
4g Could a program be developed and implemented
4g 1) Yes
4g 2) No
5 Native and domestic animals in watershed
5a No domestic animal grazing
5b No domestic animal confinement
5c Yes, domestic animal grazing or confinement with stream access
5d Yes, grazing or confinement with restricted stream access
5e Yes, domestic animal grazing or confinement within 400 feet of stream
5f Native animals
5f 1) Few native animals
5f 2) Moderate to large populations of native animals
6 Human access to and activities within watershed
6a All human access to watershed is controlled
6b Hiking, camping, picnicking, fishing or hunting
6c Snowmobiling or skiing
6d Boating
6e Swimming
6f Logging
6g Mining
7 Upstream wastewater discharges
7a Not sure if they occur
7b No known discharges occur
7c Treated municipal, no CSOs
7d Treated municipal, CSOs can occur
7e Treated industrial/commercial
7f Septic tank/drainfield within 700 feet of streams, less than 10 miles upstream
7g 1) Yes, discharges closer than 10 miles upstream of intake
7g 2) No, greater than 10 miles upstream of intake
8 Upstream stormwater discharges/runoff
8a Not sure if they occur
8b Runoff from domestic animal confinement areas < 700 feet from stream
8c Urban / Suburban stormwater runoff occurs
8d Runoff from land receiving wastes that are < 700 feet from stream
8e 1) Yes, runoff occurs less than 10 miles upstream of intake
8e 2) No, greater than 10 miles upstream of intake
9 Surface water intake structures
9a Small opening Intake screen
9b Coarse bar rack for intake screen
9c 1) Security fence and locked gate restrict access
9c 2) Livestock fence around site, only
9c 3) Posted
9c 4) None of the above, no restrictions to access
9d 1) Yes, modifying intake could result in higher quality water
9d 2) No, modifying intake would not improve water quality
10 Known source of microbial contamination
10a Yes
10b No
11 Filtration waiver
11a Yes, water system has filtration waiver for this source
11b No filtration waiver
12 Does this water source receive any form of treatment?
12a Yes
12b No
Part B: W ater Source
I. Surface W ater - Stream or River Source I. Surface W ater - Stream or River Source
No. 3 No. 3
Answer Item Item Description Comments –
1 General Current Sum of % for All
1a Stream or river source No. Water Sources= 0.0
1b Percent of annual supply (Final value should equal 100)
2 Source W ater Assessment
2a Completed
2b In-progress
2c Not yet begun
3 Source W ater Protection Program
3a In-place and followed
3b Completed, not implemented
3c Under development
3d Not yet begun
4 Management of land use and activities
4a Not sure of agency that manages land use
4b Manage some land
4c Local, State or Federal agency manages land
4d Percent of land managed by water system
4e Percent of land managed by Local, State and Federal agencies
4f Watershed too large or complex to manage
4f 1) Yes, too large or complex
4f 2) No, not too large or complex
4g Could a program be developed and implemented
4g 1) Yes
4g 2) No
5 Native and domestic animals in watershed
5a No domestic animal grazing
5b No domestic animal confinement
5c Yes, domestic animal grazing or confinement with stream access
5d Yes, grazing or confinement with restricted stream access
5e Yes, domestic animal grazing or confinement within 400 feet of stream
5f Native animals
5f 1) Few native animals
5f 2) Moderate to large populations of native animals
6 Human access to and activities within watershed
6a All human access to watershed is controlled
6b Hiking, camping, picnicking, fishing or hunting
6c Snowmobiling or skiing
6d Boating
6e Swimming
6f Logging
6g Mining
7 Upstream wastewater discharges
7a Not sure if they occur
7b No known discharges occur
7c Treated municipal, no CSOs
7d Treated municipal, CSOs can occur
7e Treated industrial/commercial
7f Septic tank/drainfield within 700 feet of streams, less than 10 miles upstream
7g 1) Yes, discharges closer than 10 miles upstream of intake
7g 2) No, greater than 10 miles upstream of intake
8 Upstream stormwater discharges/runoff
8a Not sure if they occur
8b Runoff from domestic animal confinement areas < 700 feet from stream
8c Urban / Suburban stormwater runoff occurs
8d Runoff from land receiving wastes that are < 700 feet from stream
8e 1) Yes, runoff occurs less than 10 miles upstream of intake
8e 2) No, greater than 10 miles upstream of intake
9 Surface water intake structures
9a Small opening Intake screen
9b Coarse bar rack for intake screen
9c 1) Security fence and locked gate restrict access
9c 2) Livestock fence around site, only
9c 3) Posted
9c 4) None of the above, no restrictions to access
9d 1) Yes, modifying intake could result in higher quality water
9d 2) No, modifying intake would not improve water quality
10 Known source of microbial contamination
10a Yes
10b No
11 Filtration waiver
11a Yes, water system has filtration waiver for this source
11b No filtration waiver
12 Does this water source receive any form of treatment?
12a Yes
12b No
Part B: W ater Source
I. Surface W ater - Stream or River Source I. Surface W ater - Stream or River Source
No. 4 No. 4
Answer Item Item Description Comments –
1 General Current Sum of % for All
1a Stream or river source No. Water Sources= 0.0
1b Percent of annual supply (Final value should equal 100)
2 Source W ater Assessment
2a Completed
2b In-progress
2c Not yet begun
3 Source W ater Protection Program
3a In-place and followed
3b Completed, not implemented
3c Under development
3d Not yet begun
4 Management of land use and activities
4a Not sure of agency that manages land use
4b Manage some land
4c Local, State or Federal agency manages land
4d Percent of land managed by water system
4e Percent of land managed by Local, State and Federal agencies
4f Watershed too large or complex to manage
4f 1) Yes, too large or complex
4f 2) No, not too large or complex
4g Could a program be developed and implemented
4g 1) Yes
4g 2) No
5 Native and domestic animals in watershed
5a No domestic animal grazing
5b No domestic animal confinement
5c Yes, domestic animal grazing or confinement with stream access
5d Yes, grazing or confinement with restricted stream access
5e Yes, domestic animal grazing or confinement within 400 feet of stream
5f Native animals
5f 1) Few native animals
5f 2) Moderate to large populations of native animals
6 Human access to and activities within watershed
6a All human access to watershed is controlled
6b Hiking, camping, picnicking, fishing or hunting
6c Snowmobiling or skiing
6d Boating
6e Swimming
6f Logging
6g Mining
7 Upstream wastewater discharges
7a Not sure if they occur
7b No known discharges occur
7c Treated municipal, no CSOs
7d Treated municipal, CSOs can occur
7e Treated industrial/commercial
7f Septic tank/drainfield within 700 feet of streams, less than 10 miles upstream
7g 1) Yes, discharges closer than 10 miles upstream of intake
7g 2) No, greater than 10 miles upstream of intake
8 Upstream stormwater discharges/runoff
8a Not sure if they occur
8b Runoff from domestic animal confinement areas < 700 feet from stream
8c Urban / Suburban stormwater runoff occurs
8d Runoff from land receiving wastes that are < 700 feet from stream
8e 1) Yes, runoff occurs less than 10 miles upstream of intake
8e 2) No, greater than 10 miles upstream of intake
9 Surface water intake structures
9a Small opening Intake screen
9b Coarse bar rack for intake screen
9c 1) Security fence and locked gate restrict access
9c 2) Livestock fence around site, only
9c 3) Posted
9c 4) None of the above, no restrictions to access
9d 1) Yes, modifying intake could result in higher quality water
9d 2) No, modifying intake would not improve water quality
10 Known source of microbial contamination
10a Yes
10b No
11 Filtration waiver
11a Yes, water system has filtration waiver for this source
11b No filtration waiver
12 Does this water source receive any form of treatment?
12a Yes
12b No
8/7/2012
0 No. of Stream/River Sources
0 Sum of Percent of Annual Supply for Stream/River Sources
0 Sum of Percent of Annual Supply for All Sources
100 Maximum Percent that can be Entered for No. 1
100 Maximum Percent that can be Entered for No. 2
100 Maximum Percent that can be Entered for No. 3
100 Maximum Percent that can be Entered for No. 4
0 Value = 1 if SW/ Stream Source No. 1 is NOT Treated
0 Value = 1 if SW/ Stream Source No. 2 is NOT Treated
0 Value = 1 if SW/ Stream Source No. 3 is NOT Treated
0 Value = 1 if SW/ Stream Source No. 4 is NOT Treated
0 Total No. of Untreated SW/Stream Sources
0 Value = 1 if SW/ Stream Source No. 1 is Treated
0 Value = 1 if SW/ Stream Source No. 2 is Treated
0 Value = 1 if SW/ Stream Source No. 3 is Treated
0 Value = 1 if SW/ Stream Source No. 4 is Treated
0 Total No. of Treated SW/Stream Sources
8/7/2012
Part B: W ater Source
II. Surface W ater - Lake or Impoundment II. Surface W ater - Lake or Impoundment
No. 1 No. 1
Answer Item Item Description Comments –
1 General Current Sum of % for All
1a Lake or impoundment source No. Water Sources= 0.0
1b Percent of annual supply (Final value should equal 100)
2 Source W ater Assessment
2a In-place
2b In-progress
2c Not yet begun
3 Source W ater Protection Program
3a In-place and followed
3b Completed, not implemented
3c Under development
3d Not yet begun
4 Management of land use and activities
4a Not sure what agencies manage land use and activities
4b Manage some or all land
4c Local, State or Federal agency manages land
4d Percent of land managed by water system
4e Percent of land managed by Local, State and Federal agencies
4f Watershed too large or complex to manage
4f 1) Yes, too large or complex
4f 2) No, not too large or complex
4f Could a program be developed and implemented
4g 1) Yes
4g 2) No
5 Native and domestic animals in watershed
5a No domestic animal grazing
5b No domestic animal confinement
5c Yes, domestic animal grazing or confinement with stream/lake access
5d Yes, grazing or confinement with restricted stream/lake access
5e Yes, domestic animal grazing or confinement within 400 feet of stream or lake shore
5f Native animals
5f 1) Few native animals
5f 2) Moderate to large populations of native animals
6 Human access / activities within watershed
6a All human access to watershed is controlled
6b Hiking, camping, picnicking, fishing or hunting
6c Snowmobiling or skiing
6d Boating
6e Swimming
6f Logging
6g Mining
7 Upstream wastewater discharges
7a Not sure if they occur
7b No known discharges occur
7c Treated municipal, no CSOs
7d Treated municipal, CSOs can occur
7e Treated industrial/commercial
7f Septic tank/drainfield within 700 feet of streams, less than 10 miles upstream
7g 1) Yes, discharges closer than 10 miles upstream of intake
7g 2) No, greater than 10 miles upstream of intake
8 Upstream stormwater discharges/runoff
8a Not sure if they occur
8b Runoff from domestic animal confinement areas < 700 feet from stream
8c Urban / Suburban stormwater runoff occurs
8d Runoff from land receiving wastes that are < 700 feet from stream
8e 1) Yes, runoff occurs less than 10 miles upstream of intake
8e 2) No, greater than 10 miles upstream of intake
9 W ater intake structures
9a Water can be withdrawn from variable depths
9b Screens over intake prevents entry of fish, rodents, and other animals
9c Cleaning system exists for screens
9d Access to and around intake structure
9d 1) Access restricted by security fence and gate
9d 2) Livestock fence only around intake site
9d 3) Intake area well posted
9d 4) None of the above [9d 1), 9d 2) or 9d 3)]
9e 1) Yes, higher quality water could be obtained
9e 2) No, higher quality water could not be obtained
10 Known source of microbial contamination
10a Yes
10b No
11 Filtration waiver
11a Yes, water system has filtration waiver for this source
11b No filtration waiver
12 Does this water source receive any form of treatment?
12a Yes
12b No
Part B: W ater Source
II. Surface W ater - Lake or Impoundment II. Surface W ater - Lake or Impoundment
No. 2 No. 2
Answer Item Item Description Comments –
1 General Current Sum of % for All
1a Lake or impoundment source No. Water Sources= 0.0
1b Percent of annual supply (Final value should equal 100)
2 Source W ater Assessment
2a In-place
2b In-progress
2c Not yet begun
3 Source W ater Protection Program
3a In-place and followed
3b Completed, not implemented
3c Under development
3d Not yet begun
4 Management of land use and activities
4a Not sure what agencies manage land use and activities
4b Manage some or all land
4c Local, State or Federal agency manages land
4d Percent of land managed by water system
4e Percent of land managed by Local, State and Federal agencies
4f Watershed too large or complex to manage
4f 1) Yes, too large or complex
4f 2) No, not too large or complex
4f Could a program be developed and implemented
4g 1) Yes
4g 2) No
5 Native and domestic animals in watershed
5a No domestic animal grazing
5b No domestic animal confinement
5c Yes, domestic animal grazing or confinement with stream/lake access
5d Yes, grazing or confinement with restricted stream/lake access
5e Yes, domestic animal grazing or confinement within 400 feet of stream or lake shore
5f Native animals
5f 1) Few native animals
5f 2) Moderate to large populations of native animals
6 Human access / activities within watershed
6a All human access to watershed is controlled
6b Hiking, camping, picnicking, fishing or hunting
6c Snowmobiling or skiing
6d Boating
6e Swimming
6f Logging
6g Mining
7 Upstream wastewater discharges
7a Not sure if they occur
7b No known discharges occur
7c Treated municipal, no CSOs
7d Treated municipal, CSOs can occur
7e Treated industrial/commercial
7f Septic tank/drainfield within 700 feet of streams, less than 10 miles upstream
7g 1) Yes, discharges closer than 10 miles upstream of intake
7g 2) No, greater than 10 miles upstream of intake
8 Upstream stormwater discharges/runoff
8a Not sure if they occur
8b Runoff from domestic animal confinement areas < 700 feet from stream
8c Urban / Suburban stormwater runoff occurs
8d Runoff from land receiving wastes that are < 700 feet from stream
8e 1) Yes, runoff occurs less than 10 miles upstream of intake
8e 2) No, greater than 10 miles upstream of intake
9 W ater intake structures
9a Water can be withdrawn from variable depths
9b Screens over intake prevents entry of fish, rodents, and other animals
9c Cleaning system exists for screens
9d Access to and around intake structure
9d 1) Access restricted by security fence and gate
9d 2) Livestock fence only around intake site
9d 3) Intake area well posted
9d 4) None of the above [9d 1), 9d 2) or 9d 3)]
9e 1) Yes, higher quality water could be obtained
9e 2) No, higher quality water could not be obtained
10 Known source of microbial contamination
10a Yes
10b No
11 Filtration waiver
11a Yes, water system has filtration waiver for this source
11b No filtration waiver
12 Does this water source receive any form of treatment?
12a Yes
12b No
Part B: W ater Source
II. Surface W ater - Lake or Impoundment II. Surface W ater - Lake or Impoundment
No. 3 No. 3
Answer Item Item Description Comments –
1 General Current Sum of % for All
1a Lake or impoundment source No. Water Sources= 0.0
1b Percent of annual supply (Final value should equal 100)
2 Source W ater Assessment
2a In-place
2b In-progress
2c Not yet begun
3 Source W ater Protection Program
3a In-place and followed
3b Completed, not implemented
3c Under development
3d Not yet begun
4 Management of land use and activities
4a Not sure what agencies manage land use and activities
4b Manage some or all land
4c Local, State or Federal agency manages land
4d Percent of land managed by water system
4e Percent of land managed by Local, State and Federal agencies
4f Watershed too large or complex to manage
4f 1) Yes, too large or complex
4f 2) No, not too large or complex
4f Could a program be developed and implemented
4g 1) Yes
4g 2) No
5 Native and domestic animals in watershed
5a No domestic animal grazing
5b No domestic animal confinement
5c Yes, domestic animal grazing or confinement with stream/lake access
5d Yes, grazing or confinement with restricted stream/lake access
5e Yes, domestic animal grazing or confinement within 400 feet of stream or lake shore
5f Native animals
5f 1) Few native animals
5f 2) Moderate to large populations of native animals
6 Human access / activities within watershed
6a All human access to watershed is controlled
6b Hiking, camping, picnicking, fishing or hunting
6c Snowmobiling or skiing
6d Boating
6e Swimming
6f Logging
6g Mining
7 Upstream wastewater discharges
7a Not sure if they occur
7b No known discharges occur
7c Treated municipal, no CSOs
7d Treated municipal, CSOs can occur
7e Treated industrial/commercial
7f Septic tank/drainfield within 700 feet of streams, less than 10 miles upstream
7g 1) Yes, discharges closer than 10 miles upstream of intake
7g 2) No, greater than 10 miles upstream of intake
8 Upstream stormwater discharges/runoff
8a Not sure if they occur
8b Runoff from domestic animal confinement areas < 700 feet from stream
8c Urban / Suburban stormwater runoff occurs
8d Runoff from land receiving wastes that are < 700 feet from stream
8e 1) Yes, runoff occurs less than 10 miles upstream of intake
8e 2) No, greater than 10 miles upstream of intake
9 W ater intake structures
9a Water can be withdrawn from variable depths
9b Screens over intake prevents entry of fish, rodents, and other animals
9c Cleaning system exists for screens
9d Access to and around intake structure
9d 1) Access restricted by security fence and gate
9d 2) Livestock fence only around intake site
9d 3) Intake area well posted
9d 4) None of the above [9d 1), 9d 2) or 9d 3)]
9e 1) Yes, higher quality water could be obtained
9e 2) No, higher quality water could not be obtained
10 Known source of microbial contamination
10a Yes
10b No
11 Filtration waiver
11a Yes, water system has filtration waiver for this source
11b No filtration waiver
12 Does this water source receive any form of treatment?
12a Yes
12b No
Part B: W ater Source
II. Surface W ater - Lake or Impoundment II. Surface W ater - Lake or Impoundment
No. 4 No. 4
Answer Item Item Description Comments –
1 General Current Sum of % for All
1a Lake or impoundment source No. Water Sources= 0.0
1b Percent of annual supply (Final value should equal 100)
2 Source W ater Assessment
2a In-place
2b In-progress
2c Not yet begun
3 Source W ater Protection Program
3a In-place and followed
3b Completed, not implemented
3c Under development
3d Not yet begun
4 Management of land use and activities
4a Not sure what agencies manage land use and activities
4b Manage some or all land
4c Local, State or Federal agency manages land
4d Percent of land managed by water system
4e Percent of land managed by Local, State and Federal agencies
4f Watershed too large or complex to manage
4f 1) Yes, too large or complex
4f 2) No, not too large or complex
4f Could a program be developed and implemented
4g 1) Yes
4g 2) No
5 Native and domestic animals in watershed
5a No domestic animal grazing
5b No domestic animal confinement
5c Yes, domestic animal grazing or confinement with stream/lake access
5d Yes, grazing or confinement with restricted stream/lake access
5e Yes, domestic animal grazing or confinement within 400 feet of stream or lake shore
5f Native animals
5f 1) Few native animals
5f 2) Moderate to large populations of native animals
6 Human access / activities within watershed
6a All human access to watershed is controlled
6b Hiking, camping, picnicking, fishing or hunting
6c Snowmobiling or skiing
6d Boating
6e Swimming
6f Logging
6g Mining
7 Upstream wastewater discharges
7a Not sure if they occur
7b No known discharges occur
7c Treated municipal, no CSOs
7d Treated municipal, CSOs can occur
7e Treated industrial/commercial
7f Septic tank/drainfield within 700 feet of streams, less than 10 miles upstream
7g 1) Yes, discharges closer than 10 miles upstream of intake
7g 2) No, greater than 10 miles upstream of intake
8 Upstream stormwater discharges/runoff
8a Not sure if they occur
8b Runoff from domestic animal confinement areas < 700 feet from stream
8c Urban / Suburban stormwater runoff occurs
8d Runoff from land receiving wastes that are < 700 feet from stream
8e 1) Yes, runoff occurs less than 10 miles upstream of intake
8e 2) No, greater than 10 miles upstream of intake
9 W ater intake structures
9a Water can be withdrawn from variable depths
9b Screens over intake prevents entry of fish, rodents, and other animals
9c Cleaning system exists for screens
9d Access to and around intake structure
9d 1) Access restricted by security fence and gate
9d 2) Livestock fence only around intake site
9d 3) Intake area well posted
9d 4) None of the above [9d 1), 9d 2) or 9d 3)]
9e 1) Yes, higher quality water could be obtained
9e 2) No, higher quality water could not be obtained
10 Known source of microbial contamination
10a Yes
10b No
11 Filtration waiver
11a Yes, water system has filtration waiver for this source
11b No filtration waiver
12 Does this water source receive any form of treatment?
12a Yes
12b No
8/7/2012
0 No. of Lake / Impoundment Sources
0 Sum of Percent of Annual Supply for Lake / Impoundment Sources
0 Sum of Percent of Annual Supply for All Sources
100 Maximum Percent that can be Entered for No. 1
100 Maximum Percent that can be Entered for No. 2
100 Maximum Percent that can be Entered for No. 3
100 Maximum Percent that can be Entered for No. 4
8/7/2012
0 Value = 1 if SW/ Lake Source No. 1 is NOT Treated
0 Value = 1 if SW/ Lake Source No. 2 is NOT Treated
0 Value = 1 if SW/ Lake Source No. 3 is NOT Treated
0 Value = 1 if SW/ Lake Source No. 4 is NOT Treated
0 Total No. of Untreated SW/Lake Sources
0 Value = 1 if SW/ Lake Source No. 1 is Treated
0 Value = 1 if SW/ Lake Source No. 2 is Treated
0 Value = 1 if SW/ Lake Source No. 3 is Treated
0 Value = 1 if SW/ Lake Source No. 4 is Treated
0 Total No. of Treated SW/Lake Sources
8/7/2012
Part B: W ater Source
III. Ground W ater - W ells III. Ground W ater - W ells
No. 1 No. 1
Answer Item Item Description Comments –
1 General Current Sum of % for All
1a Well source No. Water Sources= 0.0
1b Percent of annual supply (Final value should equal 100)
2 Type of water source
2a Well
2b Drilled, horizontal well collector
3 Source W ater Assessment
3a Completed
3b In-progress
3c Not yet begun
4 Source W ater Protection Program
4a In-place and followed
4b Completed, not implemented
4c Under development
4d Not yet begun
5 Management of land use and activities / Influence
5a Not sure of agency that manages land use
5b Manage some or all land
5c Local, State or Federal agency manages land
5d Percent of land managed by water system
5e Percent of land managed by Local, State and Federal agencies
5f Could a program be developed and implemented
5f 1) Yes, have resources
5f 2) No, do not have resources
6 Aquifer type
6a Do not have information
6b Confined
6c Unconfined
6d Sands/gravels along river or stream
6e Gravel, cobbles and boulders, not along stream
6f Karst
6g Fractured bedrock
6h Sand and/or silty material
6i Has this supply been determined to be GWUDISW
6i 1) Yes, it is GWUDISW
6i 2) No, it is not GWUDISW
6i 3) Classification is required, but not completed
7 Potential microbial contaminants
7a Potential contaminants in area of influence
7a 1) Septic tanks & drainfields, beds or pits within area of influence
7a 2) Confined animal pens or yards
7a 3) Gravity or pressure sewer pipes
7a 4) Waste treatment lagoons
7a 5) Dry-wells or sumps
7b Potential contaminants in immediate area of well
7b 1) Septic tanks & drainfields, beds or pits, < 200 feet from well
7b 2) Surface water, < 200 feet
7b 3) Animal pens or yards, < 200 feet
7b 4) Gravity or pressure sewer pipes, < 200 feet
7b 5) Waste treatment lagoons, < 200 feet
7b 6) Dry-wells or sumps, < 200 feet
8 W ell construction - below ground
8a Does well meet all current standards
8a 1) Yes
8a 2) No
8b Type of well
8b 1) Drilled, horizontal collector well
8b 2) Drilled well with casing pipe
8b 3) Well without casing pipe or dug well
8c Depth to static water level
8c 1) Water depth > 50 feet
8c 2) Water depth > 100 feet
8c 3) Not sure of water depth
8d Well casing grouted to depth of 20 feet or more
8e Well casing material for vertical drilled wells
8e 1) No information on casing
8e 2) Steel casing
8e 3) Stainless steel casing
8e 4) Plastic or PVC casing
8f Horizontal well collector information
8f 1) Information on Horizontal Collector not available
8f 2) Steel collectors
8f 3) Stainless steel collector
8f 4) PVC collectors
9 W ell construction - above ground
9a Drilled and cased vertical well
9a 1) Well casing extension: >18" above ground, >12" above P.S. floor; > flood elevation
9a 2) Well casing has sanitary seal over exposed end
9a 2) Well casing vent line and openings
9a 3) a) Does well casing have any openings that are not sealed?
(1) Yes
(2) No
9a 3) b) Does well casing have an air vent line?
(1) Yes
(2) No
9a 3) c) Is end of air vent line down-turned, tightly screened and above flood elevation?
(1) Yes
(2) No
9b Horizontal well collector sump or manhole, well access door/cover
9b 1) Does collector sump have an air vent line?
9b 1) a) Yes
9b 1) b) No
9b 2) Is end of vent line in down-turned position, tightly screened and above flood elevation?
9b 2) a) Yes
9b 2) b) No
9b 3) Access openings
9b 3) a) Access opening installed on raised curb
9b 3) b) Access opening has tight, sanitary door
9b 3) c) Security locks
9b 3) d) Manhole type covers are used for access doors
9b 3) e) If they exist, do manhole covers have holes?
9b 3)e)(1) Yes, manhole covers have holes
9b 3)e)(2) No, no holes in manhole covers
9c Is well location subject to flooding or surface runoff?
9c 1) Yes
9c 2) No
10 Historical Microbiological Contamination
10a Has water from this source been implicated in a waterborne disease outbreak?
10a 1) Yes
10a 2) No
10b Has water from this source tested positive for coliforms, within last 3 years?
10b 1) Yes
10b 2) No
10c If water is not treated or disinfected, has water system had any monthly coliform violations?
10c 1) Yes, within last 3 years
10c 2) No, none within last 3 years
11 Treatment of this Source
11a Water source receives treatment and/or disinfection
11b Water source does not receive treatment and/or disinfection
Part B: W ater Source
III. Ground W ater - W ells III. Ground W ater - W ells
No. 2 No. 2
Answer Item Item Description Comments –
1 General Current Sum of % for All
1a Well source No. Water Sources= 0.0
1b Percent of annual supply (Final value should equal 100)
2 Type of water source
2a Well
2b Drilled, horizontal well collector
3 Source W ater Assessment
3a Completed
3b In-progress
3c Not yet begun
4 Source W ater Protection Program
4a In-place and followed
4b Completed, not implemented
4c Under development
4d Not yet begun
5 Management of land use and activities / Influence
5a Not sure of agency that manages land use
5b Manage some or all land
5c Local, State or Federal agency manages land
5d Percent of land managed by water system
5e Percent of land managed by Local, State and Federal agencies
5f Could a program be developed and implemented
5f 1) Yes, have resources
5f 2) No, do not have resources
6 Aquifer type
6a Do not have information
6b Confined
6c Unconfined
6d Sands/gravels along river or stream
6e Gravel, cobbles and boulders, not along stream
6f Karst
6g Fractured bedrock
6h Sand and/or silty material
6i Has this supply been determined to be GWUDISW
6i 1) Yes, it is GWUDISW
6i 2) No, it is not GWUDISW
6i 3) Classification is required, but not completed
7 Potential microbial contaminants
7a Potential contaminants in area of influence
7a 1) Septic tanks & drainfields, beds or pits within area of influence
7a 2) Confined animal pens or yards
7a 3) Gravity or pressure sewer pipes
7a 4) Waste treatment lagoons
7a 5) Dry-wells or sumps
7b Potential contaminants in immediate area of well
7b 1) Septic tanks & drainfields, beds or pits, < 200 feet from well
7b 2) Surface water, < 200 feet
7b 3) Animal pens or yards, < 200 feet
7b 4) Gravity or pressure sewer pipes, < 200 feet
7b 5) Waste treatment lagoons, < 200 feet
7b 6) Dry-wells or sumps, < 200 feet
8 W ell construction - below ground
8a Does well meet all current standards
8a 1) Yes
8a 2) No
8b Type of well
8b 1) Drilled, horizontal collector well
8b 2) Drilled well with casing pipe
8b 3) Well without casing pipe or dug well
8c Depth to static water level
8c 1) Water depth > 50 feet
8c 2) Water depth > 100 feet
8c 3) Not sure of water depth
8d Well casing grouted to depth of 20 feet or more
8e Well casing material for vertical drilled wells
8e 1) No information on casing
8e 2) Steel casing
8e 3) Stainless steel casing
8e 4) Plastic or PVC casing
8f Horizontal well collector information
8f 1) Information on Horizontal Collector not available
8f 2) Steel collectors
8f 3) Stainless steel collector
8f 4) PVC collectors
9 W ell construction - above ground
9a Drilled and cased vertical well
9a 1) Well casing extension: >18" above ground, >12" above P.S. floor; > flood elevation
9a 2) Well casing has sanitary seal over exposed end
9a 2) Well casing vent line and openings
9a 3) a) Does well casing have any openings that are not sealed?
(1) Yes
(2) No
9a 3) b) Does well casing have an air vent line?
(1) Yes
(2) No
9a 3) c) Is end of air vent line down-turned, tightly screened and above flood elevation?
(1) Yes
(2) No
9b Horizontal well collector sump or manhole, well access door/cover
9b 1) Does collector sump have an air vent line?
9b 1) a) Yes
9b 1) b) No
9b 2) Is end of vent line in down-turned position, tightly screened and above flood elevation?
9b 2) a) Yes
9b 2) b) No
9b 3) Access openings
9b 3) a) Access opening installed on raised curb
9b 3) b) Access opening has tight, sanitary door
9b 3) c) Security locks
9b 3) d) Manhole type covers are used for access doors
9b 3) e) If they exist, do manhole covers have holes?
9b 3)e)(1) Yes, manhole covers have holes
9b 3)e)(2) No, no holes in manhole covers
9c Is well location subject to flooding or surface runoff?
9c 1) Yes
9c 2) No
10 Historical Microbiological Contamination
10a Has water from this source been implicated in a waterborne disease outbreak?
10a 1) Yes
10a 2) No
10b Has water from this source tested positive for coliforms, within last 3 years?
10b 1) Yes
10b 2) No
10c If water is not treated or disinfected, has water system had any monthly coliform violations?
10c 1) Yes, within last 3 years
10c 2) No, none within last 3 years
11 Treatment of this Source
11a Water source receives treatment and/or disinfection
11b Water source does not receive treatment and/or disinfection
Part B: W ater Source
III. Ground W ater - W ells III. Ground W ater - W ells
No. 3 No. 3
Answer Item Item Description Comments –
1 General Current Sum of % for All
1a Well source No. Water Sources= 0.0
1b Percent of annual supply (Final value should equal 100)
2 Type of water source
2a Well
2b Drilled, horizontal well collector
3 Source W ater Assessment
3a Completed
3b In-progress
3c Not yet begun
4 Source W ater Protection Program
4a In-place and followed
4b Completed, not implemented
4c Under development
4d Not yet begun
5 Management of land use and activities / Influence
5a Not sure of agency that manages land use
5b Manage some or all land
5c Local, State or Federal agency manages land
5d Percent of land managed by water system
5e Percent of land managed by Local, State and Federal agencies
5f Could a program be developed and implemented
5f 1) Yes, have resources
5f 2) No, do not have resources
6 Aquifer type
6a Do not have information
6b Confined
6c Unconfined
6d Sands/gravels along river or stream
6e Gravel, cobbles and boulders, not along stream
6f Karst
6g Fractured bedrock
6h Sand and/or silty material
6i Has this supply been determined to be GWUDISW
6i 1) Yes, it is GWUDISW
6i 2) No, it is not GWUDISW
6i 3) Classification is required, but not completed
7 Potential microbial contaminants
7a Potential contaminants in area of influence
7a 1) Septic tanks & drainfields, beds or pits within area of influence
7a 2) Confined animal pens or yards
7a 3) Gravity or pressure sewer pipes
7a 4) Waste treatment lagoons
7a 5) Dry-wells or sumps
7b Potential contaminants in immediate area of well
7b 1) Septic tanks & drainfields, beds or pits, < 200 feet from well
7b 2) Surface water, < 200 feet
7b 3) Animal pens or yards, < 200 feet
7b 4) Gravity or pressure sewer pipes, < 200 feet
7b 5) Waste treatment lagoons, < 200 feet
7b 6) Dry-wells or sumps, < 200 feet
8 W ell construction - below ground
8a Does well meet all current standards
8a 1) Yes
8a 2) No
8b Type of well
8b 1) Drilled, horizontal collector well
8b 2) Drilled well with casing pipe
8b 3) Well without casing pipe or dug well
8c Depth to static water level
8c 1) Water depth > 50 feet
8c 2) Water depth > 100 feet
8c 3) Not sure of water depth
8d Well casing grouted to depth of 20 feet or more
8e Well casing material for vertical drilled wells
8e 1) No information on casing
8e 2) Steel casing
8e 3) Stainless steel casing
8e 4) Plastic or PVC casing
8f Horizontal well collector information
8f 1) Information on Horizontal Collector not available
8f 2) Steel collectors
8f 3) Stainless steel collector
8f 4) PVC collectors
9 W ell construction - above ground
9a Drilled and cased vertical well
9a 1) Well casing extension: >18" above ground, >12" above P.S. floor; > flood elevation
9a 2) Well casing has sanitary seal over exposed end
9a 2) Well casing vent line and openings
9a 3) a) Does well casing have any openings that are not sealed?
(1) Yes
(2) No
9a 3) b) Does well casing have an air vent line?
(1) Yes
(2) No
9a 3) c) Is end of air vent line down-turned, tightly screened and above flood elevation?
(1) Yes
(2) No
9b Horizontal well collector sump or manhole, well access door/cover
9b 1) Does collector sump have an air vent line?
9b 1) a) Yes
9b 1) b) No
9b 2) Is end of vent line in down-turned position, tightly screened and above flood elevation?
9b 2) a) Yes
9b 2) b) No
9b 3) Access openings
9b 3) a) Access opening installed on raised curb
9b 3) b) Access opening has tight, sanitary door
9b 3) c) Security locks
9b 3) d) Manhole type covers are used for access doors
9b 3) e) If they exist, do manhole covers have holes?
9b 3)e)(1) Yes, manhole covers have holes
9b 3)e)(2) No, no holes in manhole covers
9c Is well location subject to flooding or surface runoff?
9c 1) Yes
9c 2) No
10 Historical Microbiological Contamination
10a Has water from this source been implicated in a waterborne disease outbreak?
10a 1) Yes
10a 2) No
10b Has water from this source tested positive for coliforms, within last 3 years?
10b 1) Yes
10b 2) No
10c If water is not treated or disinfected, has water system had any monthly coliform violations?
10c 1) Yes, within last 3 years
10c 2) No, none within last 3 years
11 Treatment of this Source
11a Water source receives treatment and/or disinfection
11b Water source does not receive treatment and/or disinfection
Part B: W ater Source
III. Ground W ater - W ells III. Ground W ater - W ells
No. 4 No. 4
Answer Item Item Description Comments –
1 General Current Sum of % for All
1a Well source No. Water Sources= 0.0
1b Percent of annual supply (Final value should equal 100)
8/7/2012
2 Type of water source
2a Well
2b Drilled, horizontal well collector
3 Source W ater Assessment
3a Completed
3b In-progress
3c Not yet begun
4 Source W ater Protection Program
4a In-place and followed
4b Completed, not implemented
4c Under development
4d Not yet begun
5 Management of land use and activities / Influence
5a Not sure of agency that manages land use
5b Manage some or all land
5c Local, State or Federal agency manages land
5d Percent of land managed by water system
5e Percent of land managed by Local, State and Federal agencies
5f Could a program be developed and implemented
5f 1) Yes, have resources
5f 2) No, do not have resources
6 Aquifer type
6a Do not have information
6b Confined
6c Unconfined
6d Sands/gravels along river or stream
6e Gravel, cobbles and boulders, not along stream
6f Karst
6g Fractured bedrock
6h Sand and/or silty material
6i Has this supply been determined to be GWUDISW
6i 1) Yes, it is GWUDISW
6i 2) No, it is not GWUDISW
6i 3) Classification is required, but not completed
7 Potential microbial contaminants
7a Potential contaminants in area of influence
7a 1) Septic tanks & drainfields, beds or pits within area of influence
7a 2) Confined animal pens or yards
7a 3) Gravity or pressure sewer pipes
7a 4) Waste treatment lagoons
7a 5) Dry-wells or sumps
7b Potential contaminants in immediate area of well
7b 1) Septic tanks & drainfields, beds or pits, < 200 feet from well
7b 2) Surface water, < 200 feet
7b 3) Animal pens or yards, < 200 feet
7b 4) Gravity or pressure sewer pipes, < 200 feet
7b 5) Waste treatment lagoons, < 200 feet
7b 6) Dry-wells or sumps, < 200 feet
8 W ell construction - below ground
8a Does well meet all current standards
8a 1) Yes
8a 2) No
8b Type of well
8b 1) Drilled, horizontal collector well
8b 2) Drilled well with casing pipe
8b 3) Well without casing pipe or dug well
8c Depth to static water level
8c 1) Water depth > 50 feet
8c 2) Water depth > 100 feet
8c 3) Not sure of water depth
8d Well casing grouted to depth of 20 feet or more
8e Well casing material for vertical drilled wells
8e 1) No information on casing
8e 2) Steel casing
8e 3) Stainless steel casing
8e 4) Plastic or PVC casing
8f Horizontal well collector information
8f 1) Information on Horizontal Collector not available
8f 2) Steel collectors
8f 3) Stainless steel collector
8f 4) PVC collectors
9 W ell construction - above ground
9a Drilled and cased vertical well
9a 1) Well casing extension: >18" above ground, >12" above P.S. floor; > flood elevation
9a 2) Well casing has sanitary seal over exposed end
9a 2) Well casing vent line and openings
9a 3) a) Does well casing have any openings that are not sealed?
(1) Yes
(2) No
9a 3) b) Does well casing have an air vent line?
(1) Yes
(2) No
9a 3) c) Is end of air vent line down-turned, tightly screened and above flood elevation?
(1) Yes
(2) No
9b Horizontal well collector sump or manhole, well access door/cover
9b 1) Does collector sump have an air vent line?
9b 1) a) Yes
9b 1) b) No
9b 2) Is end of vent line in down-turned position, tightly screened and above flood elevation?
9b 2) a) Yes
9b 2) b) No
9b 3) Access openings
9b 3) a) Access opening installed on raised curb
9b 3) b) Access opening has tight, sanitary door
9b 3) c) Security locks
9b 3) d) Manhole type covers are used for access doors
9b 3) e) If they exist, do manhole covers have holes?
9b 3)e)(1) Yes, manhole covers have holes
9b 3)e)(2) No, no holes in manhole covers
9c Is well location subject to flooding or surface runoff?
9c 1) Yes
9c 2) No
10 Historical Microbiological Contamination
10a Has water from this source been implicated in a waterborne disease outbreak?
10a 1) Yes
10a 2) No
10b Has water from this source tested positive for coliforms, within last 3 years?
10b 1) Yes
10b 2) No
10c If water is not treated or disinfected, has water system had any monthly coliform violations?
10c 1) Yes, within last 3 years
10c 2) No, none within last 3 years
11 Treatment of this Source
11a Water source receives treatment and/or disinfection
11b Water source does not receive treatment and/or disinfection
0 No. of Ground Water / Well Sources
0 Sum of Percent of Annual Supply for Ground Water / Well Sources
0 Sum of Percent of Annual Supply for All Sources
100 Maximum Percent that can be Entered for No. 1
100 Maximum Percent that can be Entered for No. 2
100 Maximum Percent that can be Entered for No. 3
100 Maximum Percent that can be Entered for No. 4
8/7/2012
0 Value = 1 if GW/ Well Source No. 1 is NOT Treated
0 Value = 1 if GW/ Well Source No. 2 is NOT Treated
0 Value = 1 if GW/ Well Source No. 3 is NOT Treated
0 Value = 1 if GW/ Well Source No. 4 is NOT Treated
0 Total No. of Untreated GW/Well Sources
0 Value = 1 if GW/Well Source No. 1 is Treated
0 Value = 1 if GW/Well Source No. 2 is Treated
0 Value = 1 if GW/Well Source No. 3 is Treated
0 Value = 1 if GW/Well Source No. 4 is Treated
0 Total No. of Treated GW/Well Sources
8/7/2012
Part B: W ater Source
IV. Ground W ater - Springs (includes Infiltration Galleries) IV. Ground W ater - Springs (includes Infiltration Galleries)
No. 1 No. 1
Answer Item Item Description Comments –
1 General Current Sum of % for All
1a Spring source No. Water Sources= 0.0
1b Percent of annual supply (Final value should equal 100)
2 Type of water source
2a Spring
2b Infiltration Gallery (not associated with a Spring)
3 Source W ater Assessment
3a Completed
3b In-progress
3c Not yet begun
4 Source W ater Protection Program
4a In-place and followed
4b Completed, not implemented
4c Under development
4d Not yet begun
5 Management of land use and activities / Influence
5a Not sure of agency that manages land use
5b Manage some land
5c Local, State or Federal agency manages land
5d Percent of land managed by water system
5e Percent of land managed by Local, State and Federal agencies
5f Could a program be developed and implemented
5f 1) Yes, have resources
5f 2) No, do not have resources
6 Geologic formation feeding spring
6a Do not have information
6b Confined
6c Unconfined
6d Sands/gravels along river or stream
6e Gravel, cobbles and boulders, not along stream
6f Karst
6g Fractured bedrock
6h Sand and/or silty material
6i Has this supply been determined to be GWUDISW
6i 1) Yes, it is GWUDISW
6i 2) No, it is not GWUDISW
6i 3) Classification is required, but not completed
7 Potential microbial contaminants
7a Septic tanks and drainfields, < 400 feet
7b Open irrigation ditch, stream, river, lake or pond, < 400 feet
7c Animal pens, yards or pastures, < 400 feet
7d Gravity or pressure sewer pipes, < 400 feet
7e Waste treatment lagoons, < 400 feet
7f Native game or animals such as deer or elk, < 400 feet
8 Spring/collector area protection
8a Trees, brush or deep-rooted vegetation are NOT within 50 feet
8b Stock fence exists around spring collection facilities
8c Security fence around collection facilities
8d Surface runoff and flooding potential
8d 1) Diversion channel or ditch exists
8d 2) Surface runoff or flood can reach spring site
9 Construction of spring collection facilities
9a Collection facility includes spring box and/or junction structures
9b 1) Access openings/doors on 4-inch-high riser
9b 2) Access door: tight, no rain, insects, dirt can enter spring
9b 3) Vandalism-proof security locks
9b 4) Manhole type covers are used for access
9 b 5) Do manhole covers have open holes
9b 5) a) Yes, open holes in covers
9b 5) b) No
9c 1) Yes, Structures have open joints or holes
9c 2) No holes or open joints in structures
9d 1) Yes, Spring box or collection structures have air vent lines
9d 2) No air vent lines
9e 1) Yes, air vents end in down-turned position, have tight insect screen
9e 2) No
9f Spring has buried collection pipes or laterals
9f 1) Impervious materials or liner installed over top of pipes
9f 2) Collector pipes/laterals constructed of materials that corrode
9g 1) No overflow pipe installed
9g 2) Overflow pipe discharges to atmosphere, not submerged
9g 3) End of pipes screened or have tight-closing flap gates
9h 1) Yes, water can be safely sampled without contamination of spring
9h 2) No
10 Historical Microbiological Contamination
10a Has water from this source been implicated in a waterborne disease outbreak?
10a 1) Yes
10a 2) No
10b Has water from this source tested positive for coliforms, within last 3 years?
10b 1) Yes
10b 2) No
10c If water is not treated or disinfected, has water system had any monthly coliform violations?
10c 1) Yes, within last 3 years
10c 2) No, none within last 3 years
11 Treatment of this Source
11a Water source receives treatment and/or disinfection
11b Water source does not receive treatment and/or disinfection
Part B: W ater Source
IV. Ground W ater - Springs (includes Infiltration Galleries) IV. Ground W ater - Springs (includes Infiltration Galleries)
No. 2 No. 2
Answer Item Item Description Comments –
1 General Current Sum of % for All
1a Spring source No. Water Sources= 0.0
1b Percent of annual supply (Final value should equal 100)
2 Type of water source
2a Spring
2b Infiltration Gallery (not associated with a Spring)
3 Source W ater Assessment
3a Completed
3b In-progress
3c Not yet begun
4 Source W ater Protection Program
4a In-place and followed
4b Completed, not implemented
4c Under development
4d Not yet begun
5 Management of land use and activities / Influence
5a Not sure of agency that manages land use
5b Manage some land
5c Local, State or Federal agency manages land
5d Percent of land managed by water system
5e Percent of land managed by Local, State and Federal agencies
5f Could a program be developed and implemented
5f 1) Yes, have resources
5f 2) No, do not have resources
6 Geologic formation feeding spring
6a Do not have information
6b Confined
6c Unconfined
6d Sands/gravels along river or stream
6e Gravel, cobbles and boulders, not along stream
6f Karst
6g Fractured bedrock
6h Sand and/or silty material
6i Has this supply been determined to be GWUDISW
6i 1) Yes, it is GWUDISW
6i 2) No, it is not GWUDISW
6i 3) Classification is required, but not completed
7 Potential microbial contaminants
7a Septic tanks and drainfields, < 400 feet
7b Open irrigation ditch, stream, river, lake or pond, < 400 feet
7c Animal pens, yards or pastures, < 400 feet
7d Gravity or pressure sewer pipes, < 400 feet
7e Waste treatment lagoons, < 400 feet
7f Native game or animals such as deer or elk, < 400 feet
8 Spring/collector area protection
8a Trees, brush or deep-rooted vegetation are NOT within 50 feet
8b Stock fence exists around spring collection facilities
8c Security fence around collection facilities
8d Surface runoff and flooding potential
8d 1) Diversion channel or ditch exists
8d 2) Surface runoff or flood can reach spring site
9 Construction of spring collection facilities
9a Collection facility includes spring box and/or junction structures
9b 1) Access openings/doors on 4-inch-high riser
9b 2) Access door: tight, no rain, insects, dirt can enter spring
9b 3) Vandalism-proof security locks
9b 4) Manhole type covers are used for access
9 b 5) Do manhole covers have open holes
9b 5) a) Yes, open holes in covers
9b 5) b) No
9c 1) Yes, Structures have open joints or holes
9c 2) No holes or open joints in structures
9d 1) Yes, Spring box or collection structures have air vent lines
9d 2) No air vent lines
9e 1) Yes, air vents end in down-turned position, have tight insect screen
9e 2) No
9f Spring has buried collection pipes or laterals
9f 1) Impervious materials or liner installed over top of pipes
9f 2) Collector pipes/laterals constructed of materials that corrode
9g 1) No overflow pipe installed
9g 2) Overflow pipe discharges to atmosphere, not submerged
9g 3) End of pipes screened or have tight-closing flap gates
9h 1) Yes, water can be safely sampled without contamination of spring
9h 2) No
10 Historical Microbiological Contamination
10a Has water from this source been implicated in a waterborne disease outbreak?
10a 1) Yes
10a 2) No
10b Has water from this source tested positive for coliforms, within last 3 years?
10b 1) Yes
10b 2) No
10c If water is not treated or disinfected, has water system had any monthly coliform violations?
10c 1) Yes, within last 3 years
10c 2) No, none within last 3 years
11 Treatment of this Source
11a Water source receives treatment and/or disinfection
11b Water source does not receive treatment and/or disinfection
Part B: W ater Source
IV. Ground W ater - Springs (includes Infiltration Galleries) IV. Ground W ater - Springs (includes Infiltration Galleries)
No. 3 No. 3
Answer Item Item Description Comments –
1 General Current Sum of % for All
1a Spring source No. Water Sources= 0.0
1b Percent of annual supply (Final value should equal 100)
2 Type of water source
2a Spring
2b Infiltration Gallery (not associated with a Spring)
3 Source W ater Assessment
3a Completed
3b In-progress
3c Not yet begun
4 Source W ater Protection Program
4a In-place and followed
4b Completed, not implemented
4c Under development
4d Not yet begun
5 Management of land use and activities / Influence
5a Not sure of agency that manages land use
5b Manage some land
5c Local, State or Federal agency manages land
5d Percent of land managed by water system
5e Percent of land managed by Local, State and Federal agencies
5f Could a program be developed and implemented
5f 1) Yes, have resources
5f 2) No, do not have resources
6 Geologic formation feeding spring
6a Do not have information
6b Confined
6c Unconfined
6d Sands/gravels along river or stream
6e Gravel, cobbles and boulders, not along stream
6f Karst
6g Fractured bedrock
6h Sand and/or silty material
6i Has this supply been determined to be GWUDISW
6i 1) Yes, it is GWUDISW
6i 2) No, it is not GWUDISW
6i 3) Classification is required, but not completed
7 Potential microbial contaminants
7a Septic tanks and drainfields, < 400 feet
7b Open irrigation ditch, stream, river, lake or pond, < 400 feet
7c Animal pens, yards or pastures, < 400 feet
7d Gravity or pressure sewer pipes, < 400 feet
7e Waste treatment lagoons, < 400 feet
7f Native game or animals such as deer or elk, < 400 feet
8 Spring/collector area protection
8a Trees, brush or deep-rooted vegetation are NOT within 50 feet
8b Stock fence exists around spring collection facilities
8c Security fence around collection facilities
8d Surface runoff and flooding potential
8d 1) Diversion channel or ditch exists
8d 2) Surface runoff or flood can reach spring site
9 Construction of spring collection facilities
9a Collection facility includes spring box and/or junction structures
9b 1) Access openings/doors on 4-inch-high riser
9b 2) Access door: tight, no rain, insects, dirt can enter spring
9b 3) Vandalism-proof security locks
9b 4) Manhole type covers are used for access
9 b 5) Do manhole covers have open holes
9b 5) a) Yes, open holes in covers
9b 5) b) No
9c 1) Yes, Structures have open joints or holes
9c 2) No holes or open joints in structures
9d 1) Yes, Spring box or collection structures have air vent lines
9d 2) No air vent lines
9e 1) Yes, air vents end in down-turned position, have tight insect screen
9e 2) No
9f Spring has buried collection pipes or laterals
9f 1) Impervious materials or liner installed over top of pipes
9f 2) Collector pipes/laterals constructed of materials that corrode
9g 1) No overflow pipe installed
9g 2) Overflow pipe discharges to atmosphere, not submerged
9g 3) End of pipes screened or have tight-closing flap gates
9h 1) Yes, water can be safely sampled without contamination of spring
9h 2) No
10 Historical Microbiological Contamination
10a Has water from this source been implicated in a waterborne disease outbreak?
10a 1) Yes
10a 2) No
10b Has water from this source tested positive for coliforms, within last 3 years?
10b 1) Yes
10b 2) No
10c If water is not treated or disinfected, has water system had any monthly coliform violations?
10c 1) Yes, within last 3 years
10c 2) No, none within last 3 years
11 Treatment of this Source
11a Water source receives treatment and/or disinfection
11b Water source does not receive treatment and/or disinfection
Part B: W ater Source
IV. Ground W ater - Springs (includes Infiltration Galleries) IV. Ground W ater - Springs (includes Infiltration Galleries)
No. 4 No. 4
Answer Item Item Description Comments –
1 General Current Sum of % for All
1a Spring source No. Water Sources= 0.0
1b Percent of annual supply (Final value should equal 100)
2 Type of water source
2a Spring
2b Infiltration Gallery (not associated with a Spring)
3 Source W ater Assessment
3a Completed
3b In-progress
3c Not yet begun
4 Source W ater Protection Program
4a In-place and followed
4b Completed, not implemented
4c Under development
4d Not yet begun
5 Management of land use and activities / Influence
5a Not sure of agency that manages land use
5b Manage some land
5c Local, State or Federal agency manages land
5d Percent of land managed by water system
5e Percent of land managed by Local, State and Federal agencies
5f Could a program be developed and implemented
5f 1) Yes, have resources
5f 2) No, do not have resources
6 Geologic formation feeding spring
6a Do not have information
6b Confined
6c Unconfined
6d Sands/gravels along river or stream
6e Gravel, cobbles and boulders, not along stream
6f Karst
6g Fractured bedrock
6h Sand and/or silty material
6i Has this supply been determined to be GWUDISW
6i 1) Yes, it is GWUDISW
6i 2) No, it is not GWUDISW
6i 3) Classification is required, but not completed
7 Potential microbial contaminants
7a Septic tanks and drainfields, < 400 feet
7b Open irrigation ditch, stream, river, lake or pond, < 400 feet
7c Animal pens, yards or pastures, < 400 feet
7d Gravity or pressure sewer pipes, < 400 feet
7e Waste treatment lagoons, < 400 feet
7f Native game or animals such as deer or elk, < 400 feet
8 Spring/collector area protection
8a Trees, brush or deep-rooted vegetation are NOT within 50 feet
8b Stock fence exists around spring collection facilities
8c Security fence around collection facilities
8d Surface runoff and flooding potential
8d 1) Diversion channel or ditch exists
8d 2) Surface runoff or flood can reach spring site
9 Construction of spring collection facilities
9a Collection facility includes spring box and/or junction structures
9b 1) Access openings/doors on 4-inch-high riser
9b 2) Access door: tight, no rain, insects, dirt can enter spring
9b 3) Vandalism-proof security locks
9b 4) Manhole type covers are used for access
9 b 5) Do manhole covers have open holes
9b 5) a) Yes, open holes in covers
9b 5) b) No
9c 1) Yes, Structures have open joints or holes
9c 2) No holes or open joints in structures
9d 1) Yes, Spring box or collection structures have air vent lines
9d 2) No air vent lines
9e 1) Yes, air vents end in down-turned position, have tight insect screen
9e 2) No
9f Spring has buried collection pipes or laterals
9f 1) Impervious materials or liner installed over top of pipes
9f 2) Collector pipes/laterals constructed of materials that corrode
9g 1) No overflow pipe installed
9g 2) Overflow pipe discharges to atmosphere, not submerged
9g 3) End of pipes screened or have tight-closing flap gates
9h 1) Yes, water can be safely sampled without contamination of spring
9h 2) No
10 Historical Microbiological Contamination
10a Has water from this source been implicated in a waterborne disease outbreak?
10a 1) Yes
10a 2) No
10b Has water from this source tested positive for coliforms, within last 3 years?
10b 1) Yes
10b 2) No
10c If water is not treated or disinfected, has water system had any monthly coliform violations?
10c 1) Yes, within last 3 years
10c 2) No, none within last 3 years
11 Treatment of this Source
11a Water source receives treatment and/or disinfection
11b Water source does not receive treatment and/or disinfection
8/7/2012
0 No. of Ground Water / Spring Sources
0 Sum of Percent of Annual Supply for Ground Water / Spring Sources
0 Sum of Percent of Annual Supply for All Sources
100 Maximum Percent that can be Entered for No. 1
100 Maximum Percent that can be Entered for No. 2
100 Maximum Percent that can be Entered for No. 3
100 Maximum Percent that can be Entered for No. 4
8/7/2012
0 Value = 1 if GW/ Spring Source No. 1 is NOT Treated
0 Value = 1 if GW/ Spring Source No. 2 is NOT Treated
0 Value = 1 if GW/ Spring Source No. 3 is NOT Treated
0 Value = 1 if GW/ Spring Source No. 4 is NOT Treated
0 Total No. of Untreated GW/Spring Sources
0 Value = 1 if GW/Spring Source No. 1 is Treated
0 Value = 1 if GW/Spring Source No. 2 is Treated
0 Value = 1 if GW/Spring Source No. 3 is Treated
0 Value = 1 if GW/Spring Source No. 4 is Treated
0 Total No. of Treated GW/Spring Sources
8/7/2012
Part C: Treatment
I. Surface W ater Supply Treatment–Disinfection/Corrosion Control Treatment Only I. Surface W ater Supply Treatment–Disinfection/Corrosion Control Treatment Only
No. 1 No. 1
Answer Item Item Description Comments –
1 Are disinfection/corrosion control only form of treatment?
1a Yes
1b No
2 Facility information
2a Number designation for stream or river sources (from Part B)
2a 1) Stream or river water source No.
2a 2) Stream or river water source No.
2a 3) Stream or river water source No.
2a 4) Stream or river water source No.
2b Number designation for lake or impoundment sources (from Part B)
2b 1) Lake or impoundment water source No.
2b 2) Lake or impoundment water source No. (Value can be less than 100)
2b 3) Lake or impoundment water source No. Current Sum of %
2b 4) Lake or impoundment water source No. for All Treatment
2c Percent of annual supply Facilities = 0.0
3 Filtration W aiver
3a Yes, have a filtration waiver
3b No
4 Treated W ater Quality-Turbidity-Unfiltered Supply
4a How many times turbidity >5 NTU in past 12 months?
4a 1) 0 times (never exceeded 5 NTU)
4a 2) 1 time
4a 3) 2 or more times
4b How many times turbidity >5 NTU in past 120 months?
4b 1) 0 times (never exceeded 5 NTU)
4b 2) 1 to 4 times
4b 3) 5 or more times
5 Disinfection - W ater Quality
5a Percent of time water from this treatment facility meets primary disinfection requirements
5b Disinfectant concentration in water leaving treatment facilities
5b 1) Less than 0.2 mg/L
5b 2) 0.2 to 0.5 mg/L
5b 3) 0.5 to 1.0 mg/L
5b 4) 1.0 to 1.5 mg/L
5b 5) 1.5 to 2.0 mg/L
5b 6) 2.0 to 4.0 mg/L
5b 7) Greater than 4.0 mg/L
6 Disinfection - Type
6a Type of primary disinfection system
6a 1) Chlorine (includes hypochlorite)
6a 2) Chloramines (ammonia + chlorine)
6a 3) Chlorine dioxide
6a 4) Ozone
6a 5) UV light
6a 6) Mixed oxidants
6b Type of secondary disinfectant
6b 1) Chlorine
6b 2) Chlorine dioxide
6b 3) Chloramines (ammonia + chlorine)
7 Disinfection - Facilities and Equipment
7a Sufficient capacity to meet all CxT or UV-dose requirements at all flow rates
7b Control of disinfectant feed rates
7b 1) Automatic control, flow proportional
7b 2) Automatic control, residual proportional
7b 3) Combination of 7b 1) and 7b 2)
7b 4) Manual control only
7c UV light disinfection (if it applies)
7c 1) Automatic flow rate control
7c 2) Complete back-up UV unit
7c 3) Automatic flow shut-down on loss of power
7c 4) Emergency power generator
7c 5) Back-up chlorinator if UV unit fails
7c 6) UV light dose measured and recorded
7c 7) UV units must be manually cleaned
7c 8) UV units incorporate automatic cleaning
7d Occurrences that frequently interrupt operation
7d 1) Power outage
7d 2) Equipment breakdown
7d 3) Lack of back-up equipment or spare parts
7d 4) Can water enter system if power outage occurs?
7d 4) a) Yes
7d 4) b) No
8 Disinfection System Monitoring and Alarms
8a Is disinfection system equipped with alarms?
8a 1) Yes
8a 2) No
8b Type of alarms that are triggered upon system failure
8b 1) Flashing light, horn, buzzer or other alarm indicator at facility
8b 2) Alarm sent to remote location or on-call person
9 Flow Rate Control - Treatment System
9a Flow rate control based on water demand
9b Constant, with on-off cycles
9c Flow rate controlled manually by operator
10 Treatment for corrosion control
10a Are chemicals added for corrosion control in distribution system?
10a 1) Yes
10a 2) No
10b Treatment system using chemical addition
10b 1) Adjust pH
10b 2) Phosphate, orthophosphate, polyphosphate or blends
10b 3) Silica
10b 4) Adjust alkalinity using lime or soda ash
11 Turbidity monitoring/alarms
11a Is water from this source continuously monitored for turbidity?
(i.e., an in-line turbidimeter with a recording device)
11a 1) Yes
11a 2) No
11b Does the turbidimeter have a high level alarm
11b 1) Yes
11b 2) No
11c What type of high turbidity alarms are at this facility?
11c 1) Flashing light, horn, buzzer or other visual/audio indicator at treatment facility
11c 2) Alarm is sent to an operator via telemetry or telephone auto-dialer system
12 Cross-connections
12a All units have appropriate, approved backflow prevention devices
12b Do combined air-vacuum breaker valves and float valves for control of water levels exist?
12b 1) Yes, they exist
12b 2) No, none exist
12b 3) Are all float valves located before air-vacuum breaker valves?
12b 3) a) Yes
12b 3) b) No
12c Do safety shower/eye wash stations exist that are connected to treated water?
12c 1) Yes
12c 2) No
12c 3) Are approved backflow devices installed on supply line to safety shower/eye wash units?
12c 3) a) Yes
12c 3) b) No
12d Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
12d 1) Yes
12d 2) No
12e Do all hose bib connections have vacuum breaker attached?
12e 1) Yes
12e 2) No
12f Any connections to treated water for irrigation without backflow device installed?
12f 1) Yes
12f 2) No
Part C: Treatment
I. Surface W ater Supply Treatment–Disinfection/Corrosion Control Treatment Only I. Surface W ater Supply Treatment–Disinfection/Corrosion Control Treatment Only
No. 2 No. 2
Answer Item Item Description Comments –
1 Are disinfection/corrosion control only form of treatment?
1a Yes
1b No
2 Facility information
2a Number designation for stream or river sources (from Part B)
2a 1) Stream or river water source No.
2a 2) Stream or river water source No.
2a 3) Stream or river water source No.
2a 4) Stream or river water source No.
2b Number designation for lake or impoundment sources (from Part B)
2b 1) Lake or impoundment water source No.
2b 2) Lake or impoundment water source No. (Value can be less than 100)
2b 3) Lake or impoundment water source No. Current Sum of %
2b 4) Lake or impoundment water source No. for All Treatment
2c Percent of annual supply Facilities = 0.0
3 Filtration W aiver
3a Yes, have a filtration waiver
3b No
4 Treated W ater Quality-Turbidity-Unfiltered Supply
4a How many times turbidity >5 NTU in past 12 months?
4a 1) 0 times (never exceeded 5 NTU)
4a 2) 1 time
4a 3) 2 or more times
4b How many times turbidity >5 NTU in past 120 months?
4b 1) 0 times (never exceeded 5 NTU)
4b 2) 1 to 4 times
4b 3) 5 or more times
5 Disinfection - W ater Quality
5a Percent of time water from this treatment facility meets primary disinfection requirements
5b Disinfectant concentration in water leaving treatment facilities
5b 1) Less than 0.2 mg/L
5b 2) 0.2 to 0.5 mg/L
5b 3) 0.5 to 1.0 mg/L
5b 4) 1.0 to 1.5 mg/L
5b 5) 1.5 to 2.0 mg/L
5b 6) 2.0 to 4.0 mg/L
5b 7) Greater than 4.0 mg/L
6 Disinfection - Type
6a Type of primary disinfection system
6a 1) Chlorine (includes hypochlorite)
6a 2) Chloramines (ammonia + chlorine)
6a 3) Chlorine dioxide
6a 4) Ozone
6a 5) UV light
6a 6) Mixed oxidants
6b Type of secondary disinfectant
6b 1) Chlorine
6b 2) Chlorine dioxide
6b 3) Chloramines (ammonia + chlorine)
7 Disinfection - Facilities and Equipment
7a Sufficient capacity to meet all CxT or UV-dose requirements at all flow rates
7b Control of disinfectant feed rates
7b 1) Automatic control, flow proportional
7b 2) Automatic control, residual proportional
7b 3) Combination of 7b 1) and 7b 2)
7b 4) Manual control only
7c UV light disinfection (if it applies)
7c 1) Automatic flow rate control
7c 2) Complete back-up UV unit
7c 3) Automatic flow shut-down on loss of power
7c 4) Emergency power generator
7c 5) Back-up chlorinator if UV unit fails
7c 6) UV light dose measured and recorded
7c 7) UV units must be manually cleaned
7c 8) UV units incorporate automatic cleaning
7d Occurrences that frequently interrupt operation
7d 1) Power outage
7d 2) Equipment breakdown
7d 3) Lack of back-up equipment or spare parts
7d 4) Can water enter system if power outage occurs?
7d 4) a) Yes
7d 4) b) No
8 Disinfection System Monitoring and Alarms
8a Is disinfection system equipped with alarms?
8a 1) Yes
8a 2) No
8b Type of alarms that are triggered upon system failure
8b 1) Flashing light, horn, buzzer or other alarm indicator at facility
8b 2) Alarm sent to remote location or on-call person
9 Flow Rate Control - Treatment System
9a Flow rate control based on water demand
9b Constant, with on-off cycles
9c Flow rate controlled manually by operator
10 Treatment for corrosion control
10a Are chemicals added for corrosion control in distribution system?
10a 1) Yes
10a 2) No
10b Treatment system using chemical addition
10b 1) Adjust pH
10b 2) Phosphate, orthophosphate, polyphosphate or blends
10b 3) Silica
10b 4) Adjust alkalinity using lime or soda ash
11 Turbidity monitoring/alarms
11a Is water from this source continuously monitored for turbidity?
(i.e., an in-line turbidimeter with a recording device)
11a 1) Yes
11a 2) No
11b Does the turbidimeter have a high level alarm
11b 1) Yes
11b 2) No
11c What type of high turbidity alarms are at this facility?
11c 1) Flashing light, horn, buzzer or other visual/audio indicator at treatment facility
11c 2) Alarm is sent to an operator via telemetry or telephone auto-dialer system
12 Cross-connections
12a All units have appropriate, approved backflow prevention devices
12b Do combined air-vacuum breaker valves and float valves for control of water levels exist?
12b 1) Yes, they exist
12b 2) No, none exist
12b 3) Are all float valves located before air-vacuum breaker valves?
12b 3) a) Yes
12b 3) b) No
12c Do safety shower/eye wash stations exist that are connected to treated water?
12c 1) Yes
12c 2) No
12c 3) Are approved backflow devices installed on supply line to safety shower/eye wash units?
12c 3) a) Yes
12c 3) b) No
12d Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
12d 1) Yes
12d 2) No
12e Do all hose bib connections have vacuum breaker attached?
12e 1) Yes
12e 2) No
12f Any connections to treated water for irrigation without backflow device installed?
12f 1) Yes
12f 2) No
Part C: Treatment
I. Surface W ater Supply Treatment–Disinfection/Corrosion Control Treatment Only I. Surface W ater Supply Treatment–Disinfection/Corrosion Control Treatment Only
No. 3 No. 3
Answer Item Item Description Comments –
1 Are disinfection/corrosion control only form of treatment?
1a Yes
1b No
2 Facility information
2a Number designation for stream or river sources (from Part B)
2a 1) Stream or river water source No.
2a 2) Stream or river water source No.
2a 3) Stream or river water source No.
2a 4) Stream or river water source No.
2b Number designation for lake or impoundment sources (from Part B)
2b 1) Lake or impoundment water source No.
2b 2) Lake or impoundment water source No. (Value can be less than 100)
2b 3) Lake or impoundment water source No. Current Sum of %
2b 4) Lake or impoundment water source No. for All Treatment
2c Percent of annual supply Facilities = 0.0
3 Filtration W aiver
3a Yes, have a filtration waiver
3b No
4 Treated W ater Quality-Turbidity-Unfiltered Supply
4a How many times turbidity >5 NTU in past 12 months?
4a 1) 0 times (never exceeded 5 NTU)
4a 2) 1 time
4a 3) 2 or more times
4b How many times turbidity >5 NTU in past 120 months?
4b 1) 0 times (never exceeded 5 NTU)
4b 2) 1 to 4 times
4b 3) 5 or more times
5 Disinfection - W ater Quality
5a Percent of time water from this treatment facility meets primary disinfection requirements
5b Disinfectant concentration in water leaving treatment facilities
5b 1) Less than 0.2 mg/L
5b 2) 0.2 to 0.5 mg/L
5b 3) 0.5 to 1.0 mg/L
5b 4) 1.0 to 1.5 mg/L
5b 5) 1.5 to 2.0 mg/L
5b 6) 2.0 to 4.0 mg/L
5b 7) Greater than 4.0 mg/L
6 Disinfection - Type
6a Type of primary disinfection system
6a 1) Chlorine (includes hypochlorite)
6a 2) Chloramines (ammonia + chlorine)
6a 3) Chlorine dioxide
6a 4) Ozone
6a 5) UV light
6a 6) Mixed oxidants
6b Type of secondary disinfectant
6b 1) Chlorine
6b 2) Chlorine dioxide
6b 3) Chloramines (ammonia + chlorine)
7 Disinfection - Facilities and Equipment
7a Sufficient capacity to meet all CxT or UV-dose requirements at all flow rates
7b Control of disinfectant feed rates
7b 1) Automatic control, flow proportional
7b 2) Automatic control, residual proportional
7b 3) Combination of 7b 1) and 7b 2)
7b 4) Manual control only
7c UV light disinfection (if it applies)
7c 1) Automatic flow rate control
7c 2) Complete back-up UV unit
7c 3) Automatic flow shut-down on loss of power
7c 4) Emergency power generator
7c 5) Back-up chlorinator if UV unit fails
7c 6) UV light dose measured and recorded
7c 7) UV units must be manually cleaned
7c 8) UV units incorporate automatic cleaning
7d Occurrences that frequently interrupt operation
7d 1) Power outage
7d 2) Equipment breakdown
7d 3) Lack of back-up equipment or spare parts
7d 4) Can water enter system if power outage occurs?
7d 4) a) Yes
7d 4) b) No
8 Disinfection System Monitoring and Alarms
8a Is disinfection system equipped with alarms?
8a 1) Yes
8a 2) No
8b Type of alarms that are triggered upon system failure
8b 1) Flashing light, horn, buzzer or other alarm indicator at facility
8b 2) Alarm sent to remote location or on-call person
9 Flow Rate Control - Treatment System
9a Flow rate control based on water demand
9b Constant, with on-off cycles
9c Flow rate controlled manually by operator
10 Treatment for corrosion control
10a Are chemicals added for corrosion control in distribution system?
10a 1) Yes
10a 2) No
10b Treatment system using chemical addition
10b 1) Adjust pH
10b 2) Phosphate, orthophosphate, polyphosphate or blends
10b 3) Silica
10b 4) Adjust alkalinity using lime or soda ash
11 Turbidity monitoring/alarms
11a Is water from this source continuously monitored for turbidity?
(i.e., an in-line turbidimeter with a recording device)
11a 1) Yes
11a 2) No
11b Does the turbidimeter have a high level alarm
11b 1) Yes
11b 2) No
11c What type of high turbidity alarms are at this facility?
11c 1) Flashing light, horn, buzzer or other visual/audio indicator at treatment facility
11c 2) Alarm is sent to an operator via telemetry or telephone auto-dialer system
12 Cross-connections
12a All units have appropriate, approved backflow prevention devices
12b Do combined air-vacuum breaker valves and float valves for control of water levels exist?
12b 1) Yes, they exist
12b 2) No, none exist
12b 3) Are all float valves located before air-vacuum breaker valves?
12b 3) a) Yes
12b 3) b) No
12c Do safety shower/eye wash stations exist that are connected to treated water?
12c 1) Yes
12c 2) No
12c 3) Are approved backflow devices installed on supply line to safety shower/eye wash units?
12c 3) a) Yes
8/7/2012
12c 3) b) No
12d Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
12d 1) Yes
12d 2) No
12e Do all hose bib connections have vacuum breaker attached?
12e 1) Yes
12e 2) No
12f Any connections to treated water for irrigation without backflow device installed?
12f 1) Yes
12f 2) No
Part C: Treatment
I. Surface W ater Supply Treatment–Disinfection/Corrosion Control Treatment Only I. Surface W ater Supply Treatment–Disinfection/Corrosion Control Treatment Only
No. 4 No. 4
Answer Item Item Description Comments –
1 Are disinfection/corrosion control only form of treatment?
1a Yes
1b No
2 Facility information
2a Number designation for stream or river sources (from Part B)
2a 1) Stream or river water source No.
2a 2) Stream or river water source No.
2a 3) Stream or river water source No.
2a 4) Stream or river water source No.
2b Number designation for lake or impoundment sources (from Part B)
2b 1) Lake or impoundment water source No.
2b 2) Lake or impoundment water source No. (Value can be less than 100)
2b 3) Lake or impoundment water source No. Current Sum of %
2b 4) Lake or impoundment water source No. for All Treatment
2c Percent of annual supply Facilities = 0.0
3 Filtration W aiver
3a Yes, have a filtration waiver
3b No
4 Treated W ater Quality-Turbidity-Unfiltered Supply
4a How many times turbidity >5 NTU in past 12 months?
4a 1) 0 times (never exceeded 5 NTU)
4a 2) 1 time
4a 3) 2 or more times
4b How many times turbidity >5 NTU in past 120 months?
4b 1) 0 times (never exceeded 5 NTU)
4b 2) 1 to 4 times
4b 3) 5 or more times
5 Disinfection - W ater Quality
5a Percent of time water from this treatment facility meets primary disinfection requirements
5b Disinfectant concentration in water leaving treatment facilities
5b 1) Less than 0.2 mg/L
5b 2) 0.2 to 0.5 mg/L
5b 3) 0.5 to 1.0 mg/L
5b 4) 1.0 to 1.5 mg/L
5b 5) 1.5 to 2.0 mg/L
5b 6) 2.0 to 4.0 mg/L
5b 7) Greater than 4.0 mg/L
6 Disinfection - Type
6a Type of primary disinfection system
6a 1) Chlorine (includes hypochlorite)
6a 2) Chloramines (ammonia + chlorine)
6a 3) Chlorine dioxide
6a 4) Ozone
6a 5) UV light
6a 6) Mixed oxidants
6b Type of secondary disinfectant
6b 1) Chlorine
6b 2) Chlorine dioxide
6b 3) Chloramines (ammonia + chlorine)
7 Disinfection - Facilities and Equipment
7a Sufficient capacity to meet all CxT or UV-dose requirements at all flow rates
7b Control of disinfectant feed rates
7b 1) Automatic control, flow proportional
7b 2) Automatic control, residual proportional
7b 3) Combination of 7b 1) and 7b 2)
7b 4) Manual control only
7c UV light disinfection (if it applies)
7c 1) Automatic flow rate control
7c 2) Complete back-up UV unit
7c 3) Automatic flow shut-down on loss of power
7c 4) Emergency power generator
7c 5) Back-up chlorinator if UV unit fails
7c 6) UV light dose measured and recorded
7c 7) UV units must be manually cleaned
7c 8) UV units incorporate automatic cleaning
7d Occurrences that frequently interrupt operation
7d 1) Power outage
7d 2) Equipment breakdown
7d 3) Lack of back-up equipment or spare parts
7d 4) Can water enter system if power outage occurs?
7d 4) a) Yes
7d 4) b) No
8 Disinfection System Monitoring and Alarms
8a Is disinfection system equipped with alarms?
8a 1) Yes
8a 2) No
8b Type of alarms that are triggered upon system failure
8b 1) Flashing light, horn, buzzer or other at facility
8b 2) Alarm sent to remote location or on-call person
9 Flow Rate Control - Treatment System
9a Flow rate control based on water demand
9b Constant, with on-off cycles
9c Flow rate controlled manually by operator
10 Treatment for corrosion control
10a Are chemicals added for corrosion control in distribution system?
10a 1) Yes
10a 2) No
10b Treatment system using chemical addition
10b 1) Adjust pH
10b 2) Phosphate, orthophosphate, polyphosphate or blends
10b 3) Silica
10b 4) Adjust alkalinity using lime or soda ash
11 Turbidity monitoring/alarms
11a Is water from this source continuously monitored for turbidity?
(i.e., an in-line turbidimeter with a recording device)
11a 1) Yes
11a 2) No
11b Does the turbidimeter have a high level alarm
11b 1) Yes
11b 2) No
11c What type of high turbidity alarms are at this facility?
11c 1) Flashing light, horn, buzzer or other visual/audio indicator at treatment facility
11c 2) Alarm is sent to an operator via telemetry or telephone auto-dialer system
12 Cross-connections
12a All units have appropriate, approved backflow prevention devices
12b Do combined air-vacuum breaker valves and float valves for control of water levels exist?
12b 1) Yes, they exist
12b 2) No, none exist
12b 3) Are all float valves located before air-vacuum breaker valves?
12b 3) a) Yes
12b 3) b) No
12c Do safety shower/eye wash stations exist that are connected to treated water?
12c 1) Yes
12c 2) No
12c 3) Are approved backflow devices installed on supply line to safety shower/eye wash units?
12c 3) a) Yes
12c 3) b) No
12d Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
12d 1) Yes
12d 2) No
12e Do all hose bib connections have vacuum breaker attached?
12e 1) Yes
12e 2) No
12f Any connections to treated water for irrigation without backflow device installed?
12f 1) Yes
12f 2) No
0 No. of Disinfection/Corrosion Control only Treatment Facilities for Surface Water Source(s)
0 Sum of Percent of Annual Supply for Disinfection/Corrosion Control Treatment of Surface Water Source
0 Sum of Percent of Annual Supply for All Treatment Facilities
100 Maximum Percent that can be Entered for No. 1
100 Maximum Percent that can be Entered for No. 2
100 Maximum Percent that can be Entered for No. 3
100 Maximum Percent that can be Entered for No. 4
8/7/2012
Part C: Treatment
II. Surface W ater Supply-Filtration/Disinfection/Corrosion Control Treatment II. Surface W ater Supply-Filtration/Disinfection/Corrosion Control Treatment
No. 1 No. 1
Answer Item Item Description Comments –
1 Treatment facility information
1a Facility treats surface water source(s)
1b 1) Stream or River Surface Water Source No.
1b 2) Stream or River Surface Water Source No.
1b 3) Lake or Impoundment Surface Water Source No.
1b 4) Lake or Impoundment Surface Water Source No.
1c Facility provides conventional treatment of ground water source(s)
1d 1) Well Ground Water Source No. (Value can be less than 100)
1d 2) Well Ground Water Source No. Current Sum of %
1d 3) Spring Ground Water Source No. for All Treatment
1d 4) Spring Ground Water Source No. Facilities = 0.0
1e Percent of annual supply provided by this facility
2 Treated water quality–turbidity of filtered supply
2a Is there a specific treated water turbidity goal for this facility?
2a 1) Yes
2a 2) No
2b What is the value of the specific turbidity goal, if one exists?
2b 1) Less than 0.1 NTU
2b 2) Less than 0.2 NTU
2b 3) Less than 0.3 NTU
2c Percent of time treated water meets turbidity goal as indicated above
2d Percent of time treated water meets State and EPA turbidity requirements
3 Disinfection - W ater Quality
3a Percent of time water from this treatment facility meets CxT requirements
3b Disinfectant concentration in water leaving treatment facilities
3b 1) Less than 0.2 mg/L
3b 2) 0.2 to 0.5 mg/L
3b 3) 0.5 to 1.0 mg/L
3b 4) 1.0 to 1.5 mg/L
3b 5) 1.5 to 2.0 mg/L
3b 6) 2.0 to 4.0 mg/L
3b 7) Greater than 4.0 mg/L
4 Disinfection - Type
4a Type of primary disinfection system
4a 1) Chlorine (includes hypochlorite)
4a 2) Chloramines (ammonia + chlorine)
4a 3) Chlorine dioxide
4a 4) Ozone
4a 5) UV light
4a 6) Mixed oxidants
4b Type of secondary disinfectant
4b 1) Chlorine
4b 2) Chlorine dioxide
4b 3) Chloramines (ammonia + chlorine)
5 Disinfection - Facilities and Equipment
5a Sufficient capacity to meet all CxT or UV-dose requirements at all flow rates
5b Control of disinfectant feed rates
5b 1) Automatic control, flow proportional
5b 2) Automatic control, residual proportional
5b 3) Combination of 5b 1) and 5b 2)
5b 4) Manual control only
5c UV light disinfection (if it applies)
5c 1) Automatic flow rate control
5c 2) Complete back-up UV unit
5c 3) Automatic flow shut-down on loss of power
5c 4) Emergency power generator
5c 5) Back-up chlorinator if UV unit fails
5c 6) UV light dose measured and recorded
5c 7) UV units must be manually cleaned
5c 8) UV units incorporate automatic cleaning
5d Occurrences that frequently interrupt operation
5d 1) Power outage
5d 2) Equipment breakdown
5d 3) Lack of back-up equipment or spare parts
5d 4) Can water enter system if power outage occurs?
5d 4) a) Yes
5d 4) b) No
6 Disinfection System Monitoring and Alarms
6a Is disinfection system equipped with alarms?
6a 1) Yes
6a 2) No
6b Type of alarms that are triggered upon system failure
6b 1) Flashing light, horn, buzzer or other alarm indicator at facility
6b 2) Alarm sent to remote location or on-call person
7 Flow Rate Control - Treatment System
7a Flow rate control based on water demand
7b Constant, with on-off cycles
7c Flow rate controlled manually by operator
8 Treatment for corrosion control
8a Are chemicals added for corrosion control in distribution system?
8a 1) Yes
8a 2) No
8b Treatment system using chemical addition
8b 1) Adjust pH
8b 2) Phosphate, orthophosphate or polyphosphate
8b 3) Silica
8b 4) Adjust alkalinity using lime or soda ash
9 Turbidity monitoring/alarms
9a Is treated water from this facility continuously monitored for turbidity?
(i.e., an in-line turbidimeter with a recording device)
9a 1) Yes
9a 2) No
9b Does the turbidimeter have a high level alarm
9b 1) Yes
9b 2) No
9c What type of high turbidity alarms are at this facility?
9c 1) Flashing light, horn, buzzer or other visual/audio indicator at treatment facility
9c 2) Alarm is sent to an operator via telemetry or telephone auto-dialer system
10 Control of chemical feed systems
10b Feed rates automatically controlled, proportional to flow
10c Feed rates automatically controlled, proportional to a process measurement
10d Feed rates set manually
11 Rapid mixing, flocculation and settling
11a Some form of rapid mixing is provided
11b No flocculation and settling (inline filtration)
11c Flocculation only (direct filtration)
11d Flocculation and settling (conventional treatment)
12 Filtration
12a Type of filtration system
12a 1) Not sure of the type of filtration
12a 2) Gravity, granular media
12a 3) Pressure, granular media
12a 4) Slow sand
12a 5) Membrane
12a 6) Diatomaceous earth
12b Type of membrane filtration, if it is used
12b 1) Not sure of the membrane type
12b 2) Reverse osmosis
12b 3) Nanofiltration
12b 4) Ultrafiltration
12b 5) Microfiltration
12c Flow rate control for filters
12c 1) No information on filter rate of flow controllers
12c 2) Constant rate
12c 3) Variable rate, level or demand controlled
12d Filter-to-waste
12d 1) Filter system has filter-to-waste capabilities
12d 2) Length of filter-to-waste time, minutes
12e Measurement and recording of operating data
12e 1) Turbidity
12e 1) a) Each filter or bank of membrane filters has an effluent turbidimeter
12e 1) b) Recording of turbidity
(1) Treated water turbidity automatically recorded
(2) Turbidity recorded manually
(3) Turbidity is not recorded
12e 2) Loss of head across filter or membranes
12e 2) a) Record automatically
12e 2) b) Record manually
12e 2) c) Not Recorded
12e 3) Filter run time between backwash cycles
12e 3) a) Recorded automatically
12e 3) b) Recorded manually
12e 3) c) Not Recorded
13 Filter waste backwash water recycle
13a Waste backwash water is not recycled
13b 1) Recycled to point prior to coagulant addition/rapid-mixing
13b 2) Recycled to point after coagulant addition/rapid-mixing
13b 3) Waste backwash water receives settling or other solids removal treatment before recycle
14 Cross-connections
14a All units have appropriate, approved backflow prevention devices
14b Do combined air-vacuum breaker valves and float valves for control of water levels exist?
14b 1) Yes, they exist
14b 2) No, none exist
14b 3) Are all float valves located before air-vacuum breaker valve?
14b 3) a) Yes
14b 3) b) No
14c Do safety shower/eye wash stations exist that are connected to treated water?
14c 1) Yes
14c 2) No
14c 3) Are approved backflow devices installed on supply line to safety shower/eye wash units?
14c 3) a) Yes
14c 3) b) No
14d Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
14d 1) Yes
14d 2) No
14e Do all hose bib connections have vacuum breaker attached?
14e 1) Yes
14e 2) No
14f Any connections to treated water for irrigation without backflow device installed?
14f 1) Yes
14f 2) No
Part C: Treatment
II. Surface W ater Supply-Filtration/Disinfection/Corrosion Control Treatment II. Surface W ater Supply-Filtration/Disinfection/Corrosion Control Treatment
No. 2 No. 2
Answer Item Item Description Comments –
1 Treatment facility information
1a Facility treats surface water source(s)
1b 1) Surface water source No.
1b 2) Surface water source No.
1b 3) Surface water source No.
1b 4) Surface water source No.
1c Facility provides conventional treatment of ground water source(s)
1d 1) Ground water source No. (Value can be less than 100)
1d 2) Ground water source No. Current Sum of %
1d 3) Ground water source No. for All Treatment
1d 4) Ground water source No. Facilities = 0.0
1e Percent of annual supply provided by this facility
2 Treated water quality–turbidity of filtered supply
2a Is there a specific treated water turbidity goal for this facility?
2a 1) Yes
2a 2) No
2b What is the value of the specific turbidity goal, if one exists?
2b 1) Less than 0.1 NTU
2b 2) Less than 0.2 NTU
2b 3) Less than 0.3 NTU
2c Percent of time treated water meets turbidity goal as indicated above
2d Percent of time treated water meets State and EPA turbidity requirements
3 Disinfection - W ater Quality
3a Percent of time water from this treatment facility meets CxT requirements
3b Disinfectant concentration in water leaving treatment facilities
3b 1) Less than 0.2 mg/L
3b 2) 0.2 to 0.5 mg/L
3b 3) 0.5 to 1.0 mg/L
3b 4) 1.0 to 1.5 mg/L
3b 5) 1.5 to 2.0 mg/L
3b 6) 2.0 to 4.0 mg/L
3b 7) Greater than 4.0 mg/L
4 Disinfection - Type
4a Type of primary disinfection system
4a 1) Chlorine (includes hypochlorite)
4a 2) Chloramines (ammonia + chlorine)
4a 3) Chlorine dioxide
4a 4) Ozone
4a 5) UV light
4a 6) Mixed oxidants
4b Type of secondary disinfectant
4b 1) Chlorine
4b 2) Chlorine dioxide
4b 3) Chloramines (ammonia + chlorine)
5 Disinfection - Facilities and Equipment
5a Sufficient capacity to meet all CxT or UV-dose requirements at all flow rates
5b Control of disinfectant feed rates
5b 1) Automatic control, flow proportional
5b 2) Automatic control, residual proportional
5b 3) Combination of 5b 1) and 5b 2)
5b 4) Manual control only
5c UV light disinfection (if it applies)
5c 1) Automatic flow rate control
5c 2) Complete back-up UV unit
5c 3) Automatic flow shut-down on loss of power
5c 4) Emergency power generator
5c 5) Back-up chlorinator if UV unit fails
5c 6) UV light dose measured and recorded
5c 7) UV units must be manually cleaned
5c 8) UV units incorporate automatic cleaning
5d Occurrences that frequently interrupt operation
5d 1) Power outage
5d 2) Equipment breakdown
5d 3) Lack of back-up equipment or spare parts
5d 4) Can water enter system if power outage occurs?
5d 4) a) Yes
5d 4) b) No
6 Disinfection System Monitoring and Alarms
6a Is disinfection system equipped with alarms?
6a 1) Yes
6a 2) No
6b Type of alarms that are triggered upon system failure
6b 1) Flashing light, horn, buzzer or other alarm indicator at facility
6b 2) Alarm sent to remote location or on-call person
7 Flow Rate Control - Treatment System
7a Flow rate control based on water demand
7b Constant, with on-off cycles
7c Flow rate controlled manually by operator
8 Treatment for corrosion control
8a Are chemicals added for corrosion control in distribution system?
8a 1) Yes
8a 2) No
8b Treatment system using chemical addition
8b 1) Adjust pH
8b 2) Phosphate, orthophosphate or polyphosphate
8b 3) Silica
8b 4) Adjust alkalinity using lime or soda ash
9 Turbidity monitoring/alarms
9a Is treated water from this facility continuously monitored for turbidity?
(i.e., an in-line turbidimeter with a recording device)
9a 1) Yes
9a 2) No
9b Does the turbidimeter have a high level alarm
9b 1) Yes
9b 2) No
9c What type of high turbidity alarms are at this facility?
9c 1) Flashing light, horn, buzzer or other visual/audio indicator at treatment facility
9c 2) Alarm is sent to an operator via telemetry or telephone auto-dialer system
10 Control of chemical feed systems
10b Feed rates automatically controlled, proportional to flow
10c Feed rates automatically controlled, proportional to a process measurement
10d Feed rates set manually
11 Rapid mixing, flocculation and settling
11a Some form of rapid mixing is provided
11b No flocculation and settling (inline filtration)
11c Flocculation only (direct filtration)
11d Flocculation and settling (conventional treatment)
12 Filtration
12a Type of filtration system
12a 1) Not sure of the type of filtration
12a 2) Gravity, granular media
12a 3) Pressure, granular media
12a 4) Slow sand
12a 5) Membrane
12a 6) Diatomaceous earth
12b Type of membrane filtration, if it is used
12b 1) Not sure of the membrane type
12b 2) Reverse osmosis
12b 3) Nanofiltration
12b 4) Ultrafiltration
12b 5) Microfiltration
12c Flow rate control for filters
12c 1) No information on filter rate of flow controllers
12c 2) Constant rate
12c 3) Variable rate, level or demand controlled
12d Filter-to-waste
12d 1) Filter system has filter-to-waste capabilities
12d 2) Length of filter-to-waste time, minutes
12e Measurement and recording of operating data
12e 1) Turbidity
12e 1) a) Each filter or bank of membrane filters has an effluent turbidimeter
12e 1) b) Recording of turbidity
(1) Treated water turbidity automatically recorded
(2) Turbidity recorded manually
(3) Turbidity is not recorded
12e 2) Loss of head across filter or membranes
12e 2) a) Record automatically
12e 2) b) Record manually
12e 2) c) Not Recorded
12e 3) Filter run time between backwash cycles
12e 3) a) Recorded automatically
12e 3) b) Recorded manually
12e 3) c) Not Recorded
13 Filter waste backwash water recycle
13a Waste backwash water is not recycled
13b 1) Recycled to point prior to coagulant addition/rapid-mixing
13b 2) Recycled to point after coagulant addition/rapid-mixing
13b 3) Waste backwash water receives settling or other solids removal treatment before recycle
14 Cross-connections
14a All units have appropriate, approved backflow prevention devices
14b Do combined air-vacuum breaker valves and float valves for control of water levels exist?
14b 1) Yes, they exist
14b 2) No, none exist
14b 3) Are all float valves located before air-vacuum breaker valve?
14b 3) a) Yes
14b 3) b) No
14c Do safety shower/eye wash stations exist that are connected to treated water?
14c 1) Yes
14c 2) No
14c 3) Are approved backflow devices installed on supply line to safety shower/eye wash units?
14c 3) a) Yes
14c 3) b) No
14d Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
14d 1) Yes
14d 2) No
14e Do all hose bib connections have vacuum breaker attached?
14e 1) Yes
14e 2) No
14f Any connections to treated water for irrigation without backflow device installed?
14f 1) Yes
14f 2) No
Part C: Treatment
II. Surface W ater Supply-Filtration/Disinfection/Corrosion Control Treatment II. Surface W ater Supply-Filtration/Disinfection/Corrosion Control Treatment
No. 3 No. 3
Answer Item Item Description Comments –
1 Treatment facility information
1a Facility treats surface water source(s)
1b 1) Surface water source No.
1b 2) Surface water source No.
1b 3) Surface water source No.
1b 4) Surface water source No.
1c Facility provides conventional treatment of ground water source(s)
1d 1) Ground water source No. (Value can be less than 100)
1d 2) Ground water source No. Current Sum of %
1d 3) Ground water source No. for All Treatment
1d 4) Ground water source No. Facilities = 0.0
1e Percent of annual supply provided by this facility
2 Treated water quality–turbidity of filtered supply
2a Is there a specific treated water turbidity goal for this facility?
2a 1) Yes
2a 2) No
2b What is the value of the specific turbidity goal, if one exists?
2b 1) Less than 0.1 NTU
2b 2) Less than 0.2 NTU
2b 3) Less than 0.3 NTU
2c Percent of time treated water meets turbidity goal as indicated above
2d Percent of time treated water meets State and EPA turbidity requirements
3 Disinfection - W ater Quality
3a Percent of time water from this treatment facility meets CxT requirements
3b Disinfectant concentration in water leaving treatment facilities
3b 1) Less than 0.2 mg/L
8/7/2012
3b 2) 0.2 to 0.5 mg/L
3b 3) 0.5 to 1.0 mg/L
3b 4) 1.0 to 1.5 mg/L
3b 5) 1.5 to 2.0 mg/L
3b 6) 2.0 to 4.0 mg/L
3b 7) Greater than 4.0 mg/L
4 Disinfection - Type
4a Type of primary disinfection system
4a 1) Chlorine (includes hypochlorite)
4a 2) Chloramines (ammonia + chlorine)
4a 3) Chlorine dioxide
4a 4) Ozone
4a 5) UV light
4a 6) Mixed oxidants
4b Type of secondary disinfectant
4b 1) Chlorine
4b 2) Chlorine dioxide
4b 3) Chloramines (ammonia + chlorine)
5 Disinfection - Facilities and Equipment
5a Sufficient capacity to meet all CxT or UV-dose requirements at all flow rates
5b Control of disinfectant feed rates
5b 1) Automatic control, flow proportional
5b 2) Automatic control, residual proportional
5b 3) Combination of 5b 1) and 5b 2)
5b 4) Manual control only
5c UV light disinfection (if it applies)
5c 1) Automatic flow rate control
5c 2) Complete back-up UV unit
5c 3) Automatic flow shut-down on loss of power
5c 4) Emergency power generator
5c 5) Back-up chlorinator if UV unit fails
5c 6) UV light dose measured and recorded
5c 7) UV units must be manually cleaned
5c 8) UV units incorporate automatic cleaning
5d Occurrences that frequently interrupt operation
5d 1) Power outage
5d 2) Equipment breakdown
5d 3) Lack of back-up equipment or spare parts
5d 4) Can water enter system if power outage occurs?
5d 4) a) Yes
5d 4) b) No
6 Disinfection System Monitoring and Alarms
6a Is disinfection system equipped with alarms?
6a 1) Yes
6a 2) No
6b Type of alarms that are triggered upon system failure
6b 1) Flashing light, horn, buzzer or other alarm indicator at facility
6b 2) Alarm sent to remote location or on-call person
7 Flow Rate Control - Treatment System
7a Flow rate control based on water demand
7b Constant, with on-off cycles
7c Flow rate controlled manually by operator
8 Treatment for corrosion control
8a Are chemicals added for corrosion control in distribution system?
8a 1) Yes
8a 2) No
8b Treatment system using chemical addition
8b 1) Adjust pH
8b 2) Phosphate, orthophosphate or polyphosphate
8b 3) Silica
8b 4) Adjust alkalinity using lime or soda ash
9 Turbidity monitoring/alarms
9a Is treated water from this facility continuously monitored for turbidity?
(i.e., an in-line turbidimeter with a recording device)
9a 1) Yes
9a 2) No
9b Does the turbidimeter have a high level alarm
9b 1) Yes
9b 2) No
9c What type of high turbidity alarms are at this facility?
9c 1) Flashing light, horn, buzzer or other visual/audio indicator at treatment facility
9c 2) Alarm is sent to an operator via telemetry or telephone auto-dialer system
10 Control of chemical feed systems
10b Feed rates automatically controlled, proportional to flow
10c Feed rates automatically controlled, proportional to a process measurement
10d Feed rates set manually
11 Rapid mixing, flocculation and settling
11a Some form of rapid mixing is provided
11b No flocculation and settling (inline filtration)
11c Flocculation only (direct filtration)
11d Flocculation and settling (conventional treatment)
12 Filtration
12a Type of filtration system
12a 1) Not sure of the type of filtration
12a 2) Gravity, granular media
12a 3) Pressure, granular media
12a 4) Slow sand
12a 5) Membrane
12a 6) Diatomaceous earth
12b Type of membrane filtration, if it is used
12b 1) Not sure of the membrane type
12b 2) Reverse osmosis
12b 3) Nanofiltration
12b 4) Ultrafiltration
12b 5) Microfiltration
12c Flow rate control for filters
12c 1) No information on filter rate of flow controllers
12c 2) Constant rate
12c 3) Variable rate, level or demand controlled
12d Filter-to-waste
12d 1) Filter system has filter-to-waste capabilities
12d 2) Length of filter-to-waste time, minutes
12e Measurement and recording of operating data
12e 1) Turbidity
12e 1) a) Each filter or bank of membrane filters has an effluent turbidimeter
12e 1) b) Recording of turbidity
(1) Treated water turbidity automatically recorded
(2) Turbidity recorded manually
(3) Turbidity is not recorded
12e 2) Loss of head across filter or membranes
12e 2) a) Record automatically
12e 2) b) Record manually
12e 2) c) Not Recorded
12e 3) Filter run time between backwash cycles
12e 3) a) Recorded automatically
12e 3) b) Recorded manually
12e 3) c) Not Recorded
13 Filter waste backwash water recycle
13a Waste backwash water is not recycled
13b 1) Recycled to point prior to coagulant addition/rapid-mixing
13b 2) Recycled to point after coagulant addition/rapid-mixing
13b 3) Waste backwash water receives settling or other solids removal treatment before recycle
14 Cross-connections
14a All units have appropriate, approved backflow prevention devices
14b Do combined air-vacuum breaker valves and float valve for control of water level exist?
14b 1) Yes, they exist
14b 2) No, none exist
14b 3) Are all float valves located before air-vacuum breaker valve?
14b 3) a) Yes
14b 3) b) No
14c Do safety shower/eye wash stations exist that are connected to treated water?
14c 1) Yes
14c 2) No
14c 3) Are approved backflow devices installed on supply line to safety shower/eye wash units?
14c 3) a) Yes
14c 3) b) No
14d Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
14d 1) Yes
14d 2) No
14e Do all hose bib connections have vacuum breaker attached?
14e 1) Yes
14e 2) No
14f Any connections to treated water for irrigation without backflow device installed?
14f 1) Yes
14f 2) No
Part C: Treatment
II. Surface W ater Supply-Filtration/Disinfection/Corrosion Control Treatment II. Surface W ater Supply-Filtration/Disinfection/Corrosion Control Treatment
No.4 No.4
Answer Item Item Description Comments –
1 Treatment facility information
1a Facility treats surface water source(s)
1b 1) Surface water source No.
1b 2) Surface water source No.
1b 3) Surface water source No.
1b 4) Surface water source No.
1c Facility provides conventional treatment of ground water source(s)
1d 1) Ground water source No. (Value can be less than 100)
1d 2) Ground water source No. Current Sum of %
1d 3) Ground water source No. for All Treatment
1d 4) Ground water source No. Facilities = 0.0
1e Percent of annual supply provided by this facility
2 Treated water quality–turbidity of filtered supply
2a Is there a specific treated water turbidity goal for this facility?
2a 1) Yes
2a 2) No
2b What is the value of the specific turbidity goal, if one exists?
2b 1) Less than 0.1 NTU
2b 2) Less than 0.2 NTU
2b 3) Less than 0.3 NTU
2c Percent of time treated water meets turbidity goal as indicated above
2d Percent of time treated water meets State and EPA turbidity requirements
3 Disinfection - W ater Quality
3a Percent of time water from this treatment facility meets CxT requirements
3b Disinfectant concentration in water leaving treatment facilities
3b 1) Less than 0.2 mg/L
3b 2) 0.2 to 0.5 mg/L
3b 3) 0.5 to 1.0 mg/L
3b 4) 1.0 to 1.5 mg/L
3b 5) 1.5 to 2.0 mg/L
3b 6) 2.0 to 4.0 mg/L
3b 7) Greater than 4.0 mg/L
4 Disinfection - Type
4a Type of primary disinfection system
4a 1) Chlorine (includes hypochlorite)
4a 2) Chloramines (ammonia + chlorine)
4a 3) Chlorine dioxide
4a 4) Ozone
4a 5) UV light
4a 6) Mixed oxidants
4b Type of secondary disinfectant
4b 1) Chlorine
4b 2) Chlorine dioxide
4b 3) Chloramines (ammonia + chlorine)
5 Disinfection - Facilities and Equipment
5a Sufficient capacity to meet all CxT or UV-dose requirements at all flow rates
5b Control of disinfectant feed rates
5b 1) Automatic control, flow proportional
5b 2) Automatic control, residual proportional
5b 3) Combination of 5b 1) and 5b 2)
5b 4) Manual control only
5c UV light disinfection (if it applies)
5c 1) Automatic flow rate control
5c 2) Complete back-up UV unit
5c 3) Automatic flow shut-down on loss of power
5c 4) Emergency power generator
5c 5) Back-up chlorinator if UV unit fails
5c 6) UV light dose measured and recorded
5c 7) UV units must be manually cleaned
5c 8) UV units incorporate automatic cleaning
5d Occurrences that frequently interrupt operation
5d 1) Power outage
5d 2) Equipment breakdown
5d 3) Lack of back-up equipment or spare parts
5d 4) Can water enter system if power outage occurs?
5d 4) a) Yes
5d 4) b) No
6 Disinfection System Monitoring and Alarms
6a Is disinfection system equipped with alarms?
6a 1) Yes
6a 2) No
6b Type of alarms that are triggered upon system failure
6b 1) Flashing light, horn, buzzer or other alarm indicator at facility
6b 2) Alarm sent to remote location or on-call person
7 Flow Rate Control - Treatment System
7a Flow rate control based on water demand
7b Constant, with on-off cycles
7c Flow rate controlled manually by operator
8 Treatment for corrosion control
8a Are chemicals added for corrosion control in distribution system?
8a 1) Yes
8a 2) No
8b Treatment system using chemical addition
8b 1) Adjust pH
8b 2) Phosphate, orthophosphate or polyphosphate
8b 3) Silica
8b 4) Adjust alkalinity using lime or soda ash
9 Turbidity monitoring/alarms
9a Is treated water from this facility continuously monitored for turbidity?
(i.e., an in-line turbidimeter with a recording device)
9a 1) Yes
9a 2) No
9b Does the turbidimeter have a high level alarm
9b 1) Yes
9b 2) No
9c What type of high turbidity alarms are at this facility?
9c 1) Flashing light, horn, buzzer or other visual/audio indicator at treatment facility
9c 2) Alarm is sent to an operator via telemetry or telephone auto-dialer system
10 Control of chemical feed systems
10b Feed rates automatically controlled, proportional to flow
10c Feed rates automatically controlled, proportional to a process measurement
10d Feed rates set manually
11 Rapid mixing, flocculation and settling
11a Some form of rapid mixing is provided
11b No flocculation and settling (inline filtration)
11c Flocculation only (direct filtration)
11d Flocculation and settling (conventional treatment)
12 Filtration
12a Type of filtration system
12a 1) Not sure of the type of filtration
12a 2) Gravity, granular media
12a 3) Pressure, granular media
12a 4) Slow sand
12a 5) Membrane
12a 6) Diatomaceous earth
12b Type of membrane filtration, if it is used
12b 1) Not sure of the membrane type
12b 2) Reverse osmosis
12b 3) Nanofiltration
12b 4) Ultrafiltration
12b 5) Microfiltration
12c Flow rate control for filters
12c 1) No information on filter rate of flow controllers
12c 2) Constant rate
12c 3) Variable rate, level or demand controlled
12d Filter-to-waste
12d 1) Filter system has filter-to-waste capabilities
12d 2) Length of filter-to-waste time, minutes
12e Measurement and recording of operating data
12e 1) Turbidity
12e 1) a) Each filter or bank of membrane filters has an effluent turbidimeter
12e 1) b) Recording of turbidity
(1) Treated water turbidity automatically recorded
(2) Turbidity recorded manually
(3) Turbidity is not recorded
12e 2) Loss of head across filter or membranes
12e 2) a) Record automatically
12e 2) b) Record manually
12e 2) c) Not Recorded
12e 3) Filter run time between backwash cycles
12e 3) a) Recorded automatically
12e 3) b) Recorded manually
12e 3) c) Not Recorded
13 Filter waste backwash water recycle
13a Waste backwash water is not recycled
13b 1) Recycled to point prior to coagulant addition/rapid-mixing
13b 2) Recycled to point after coagulant addition/rapid-mixing
13b 3) Waste backwash water receives settling or other solids removal treatment before recycle
14 Cross-connections
14a All units have appropriate, approved backflow prevention devices
14b Do combined air-vacuum breaker valves and float valve for control of water level exist?
14b 1) Yes, they exist
14b 2) No, none exist
14b 3) Are all float valves located before air-vacuum breaker valve?
14b 3) a) Yes
14b 3) b) No
14c Do safety shower/eye wash stations exist that are connected to treated water?
14c 1) Yes
14c 2) No
14c 3) Are approved backflow devices installed on supply line to safety shower/eye wash units?
14c 3) a) Yes
14c 3) b) No
14d Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
14d 1) Yes
14d 2) No
14e Do all hose bib connections have vacuum breaker attached?
14e 1) Yes
14e 2) No
14f Any connections to treated water for irrigation without backflow device installed?
14f 1) Yes
14f 2) No
0 No. of Filtration/Disinfection/Corrosion Control Treatment Facilities for Surface Water Source(s)
0 Sum of Percent of Annual Supply for Filtration/Disinfection/Corrosion Control Treatment of Surface Water Source(s)
0 Sum of Percent of Annual Supply for All Treatment Facilities
100 Maximum Percent that can be Entered for No. 1
100 Maximum Percent that can be Entered for No. 2
100 Maximum Percent that can be Entered for No. 3
100 Maximum Percent that can be Entered for No. 4
8/7/2012
Part C: Treatment
III. Ground W ater Supply – Disinfection/Corrosion Control Treatment Only III. Ground W ater Supply – Disinfection/Corrosion Control Treatment Only
No. 1 No. 1
Answer Item Item Description Comments –
2 Are disinfection/corrosion control only form of treatment?
2a Yes
2b No
3 Facility information
3a 1) Well Ground Water Source No.
3a 2) Well Ground Water Source No. (Value can be less than 100)
3a 3) Spring Ground Water Source No. Current Sum of %
3a 4) Spring Ground Water Source No. for All Treatment
3b Percent of annual supply Facilities = 0.0
4 Disinfection - Residual Concentration
4 Disinfectant concentration in water leaving treatment facilities
4a Less than 0.2 mg/L
4b 0.2 to 0.5 mg/L
4c 0.5 to 1.0 mg/L
4d 1.0 to 1.5 mg/L
4e 1.5 to 2.0 mg/L
4f 2.0 to 4.0 mg/L
4g Greater than 4.0 mg/L
5 Disinfection - Type
5a Type of disinfection system
5a 1) Chlorine (includes hypochlorite)
5a 2) Chloramines (ammonia + chlorine)
5a 3) Chlorine dioxide
5a 4) Ozone
5a 5) UV light
5a 6) Mixed oxidants
5b Type of secondary disinfectant if UV-light or ozone used as primary disinfectant
5b 1) Chlorine
5b 2) Chlorine dioxide
5b 3) Chloramines (ammonia + chlorine)
6 Disinfection - Facilities and Equipment
6a Sufficient capacity to meet all CT requirements and flow rates
6b Control of disinfectant feed rates
6b 1) Automatic control, flow proportional
6b 2) Automatic control, residual proportional
6b 3) Combination of 6b 1) and 6b 2)
6b 4) Manual control only
6c UV light disinfection (if it applies)
6c 1) Automatic flow rate control
6c 2) Complete back-up UV unit
6c 3) Automatic flow shut-down on loss of power
6c 4) Emergency power generator
6c 5) Back-up chlorinator if UV unit fails
6c 6) UV light dose measured and recorded
6c 7) UV units must be manually cleaned
6c 8) UV units incorporate automatic cleaning
6d Occurrences that frequently interrupt operation
6d 1) Power outage
6d 2) Equipment breakdown
6d 3) Lack of back-up equipment or spare parts
6d 4) Can water enter system if power outage occurs?
6d 4) a) Yes
6d 4) b) No
7 Disinfection System Monitoring and Alarms
7a Is disinfection system equipped with alarms?
7a 1) Yes
7a 2) No
7b Type of alarms that are triggered upon system failure
7b 1) Flashing light, horn, buzzer or other alarm indicator at facility
7b 2) Alarm sent to remote location or on-call person
8 Flow Rate Control - Treatment System
8a Flow rate control based on water demand
8b Constant, with on-off cycles
8c Flow rate controlled manually by operator
9 Treatment for corrosion control
9a Are chemicals added for corrosion control in distribution system?
9a 1) Yes
9a 2) No
9b Treatment system using chemical addition
9b 1) Adjust pH
9b 2) Phosphate, orthophosphate or polyphosphate
9b 3) Silica
9b 4) Adjust alkalinity using lime or soda ash
10 Turbidity monitoring/alarms
10a Is water from this source continuously monitored for turbidity?
(i.e., an in-line turbidimeter with a recording device)
10a 1) Yes
10a 2) No
10b Does the turbidimeter have a high level alarm
10b 1) Yes
10b 2) No
10c What type of high turbidity alarms are at this facility?
10c 1) Flashing light, horn, buzzer or other visual/audio indicator at treatment facility
10c 2) Alarm is sent to an operator via telemetry or telephone auto-dialer system
11 Cross-connections
11a All units have appropriate, approved backflow prevention devices
11b Do combined air-vacuum breaker valves and float valves for control of water levels exist?
11b 1) Yes, they exist
11b 2) No, none exist
11b 3) Are all float valves located before air-vacuum breaker valve?
11b 3) a) Yes
11b 3) b) No
11c Do safety shower/eye wash stations exist that are connected to treated water?
11c 1) Yes
11c 2) No
11c 3) Are approved backflow devices installed on supply line to safety shower/eye wash units?
11c 3) a) Yes
11c 3) b) No
11d Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
11d 1) Yes
11d 2) No
11e Do all hose bib connections have vacuum breaker attached?
11e 1) Yes
11e 2) No
11f Any connections to treated water for irrigation without backflow device installed?
11f 1) Yes
11f 2) No
Part C: Treatment
III. Ground W ater Supply – Disinfection/Corrosion Control Treatment Only III. Ground W ater Supply – Disinfection/Corrosion Control Treatment Only
No. 2 No. 2
Answer Item Item Description Comments –
2 Are disinfection/corrosion control only form of treatment?
2a Yes
2b No
3 Facility information
3a 1) Well Ground Water Source No.
3a 2) Well Ground Water Source No. (Value can be less than 100)
3a 3) Spring Ground Water Source No. Current Sum of %
3a 4) Spring Ground Water Source No. for All Treatment
3b Percent of annual supply Facilities = 0.0
4 Disinfection - Residual Concentration
4 Disinfectant concentration in water leaving treatment facilities
4a Less than 0.2 mg/L
4b 0.2 to 0.5 mg/L
4c 0.5 to 1.0 mg/L
4d 1.0 to 1.5 mg/L
4e 1.5 to 2.0 mg/L
4f 2.0 to 4.0 mg/L
4g Greater than 4.0 mg/L
5 Disinfection - Type
5a Type of disinfection system
5a 1) Chlorine (includes hypochlorite)
5a 2) Chloramines (ammonia + chlorine)
5a 3) Chlorine dioxide
5a 4) Ozone
5a 5) UV light
5a 6) Mixed oxidants
5b Type of secondary disinfectant if UV-light or ozone used as primary disinfectant
5b 1) Chlorine
5b 2) Chlorine dioxide
5b 3) Chloramines (ammonia + chlorine)
6 Disinfection - Facilities and Equipment
6a Sufficient capacity to meet all CT requirements and flow rates
6b Control of disinfectant feed rates
6b 1) Automatic control, flow proportional
6b 2) Automatic control, residual proportional
6b 3) Combination of 6b 1) and 6b 2)
6b 4) Manual control only
6c UV light disinfection (if it applies)
6c 1) Automatic flow rate control
6c 2) Complete back-up UV unit
6c 3) Automatic flow shut-down on loss of power
6c 4) Emergency power generator
6c 5) Back-up chlorinator if UV unit fails
6c 6) UV light dose measured and recorded
6c 7) UV units must be manually cleaned
6c 8) UV units incorporate automatic cleaning
6d Occurrences that frequently interrupt operation
6d 1) Power outage
6d 2) Equipment breakdown
6d 3) Lack of back-up equipment or spare parts
6d 4) Can water enter system if power outage occurs?
6d 4) a) Yes
6d 4) b) No
7 Disinfection System Monitoring and Alarms
7a Is disinfection system equipped with alarms?
7a 1) Yes
7a 2) No
7b Type of alarms that are triggered upon system failure
7b 1) Flashing light, horn, buzzer or other alarm indicator at facility
7b 2) Alarm sent to remote location or on-call person
8 Flow Rate Control - Treatment System
8a Flow rate control based on water demand
8b Constant, with on-off cycles
8c Flow rate controlled manually by operator
9 Treatment for corrosion control
9a Are chemicals added for corrosion control in distribution system?
9a 1) Yes
9a 2) No
9b Treatment system using chemical addition
9b 1) Adjust pH
9b 2) Phosphate, orthophosphate or polyphosphate
9b 3) Silica
9b 4) Adjust alkalinity using lime or soda ash
10 Turbidity monitoring/alarms
10a Is water from this source continuously monitored for turbidity?
(i.e., an in-line turbidimeter with a recording device)
10a 1) Yes
10a 2) No
10b Does the turbidimeter have a high level alarm
10b 1) Yes
10b 2) No
10c What type of high turbidity alarms are at this facility?
10c 1) Flashing light, horn, buzzer or other visual/audio indicator at treatment facility
10c 2) Alarm is sent to an operator via telemetry or telephone auto-dialer system
11 Cross-connections
11a All units have appropriate, approved backflow prevention devices
11b Do combined air-vacuum breaker valves and float valves for control of water levels exist?
11b 1) Yes, they exist
11b 2) No, none exist
11b 3) Are all float valves located before air-vacuum breaker valve?
11b 3) a) Yes
11b 3) b) No
11c Do safety shower/eye wash stations exist that are connected to treated water?
11c 1) Yes
11c 2) No
11c 3) Are approved backflow devices installed on supply line to safety shower/eye wash units?
11c 3) a) Yes
11c 3) b) No
11d Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
11d 1) Yes
11d 2) No
11e Do all hose bib connections have vacuum breaker attached?
11e 1) Yes
11e 2) No
11f Any connections to treated water for irrigation without backflow device installed?
11f 1) Yes
11f 2) No
Part C: Treatment
III. Ground W ater Supply – Disinfection/Corrosion Control Treatment Only III. Ground W ater Supply – Disinfection/Corrosion Control Treatment Only
No. 3 No. 3
Answer Item Item Description Comments –
2 Are disinfection/corrosion control only form of treatment?
2a Yes
2b No
3 Facility information
3a 1) Well Ground Water Source No.
3a 2) Well Ground Water Source No. (Value can be less than 100)
3a 3) Spring Ground Water Source No. Current Sum of %
3a 4) Spring Ground Water Source No. for All Treatment
3b Percent of annual supply Facilities = 0.0
4 Disinfection - Residual Concentration
4 Disinfectant concentration in water leaving treatment facilities
4a Less than 0.2 mg/L
4b 0.2 to 0.5 mg/L
4c 0.5 to 1.0 mg/L
4d 1.0 to 1.5 mg/L
4e 1.5 to 2.0 mg/L
4f 2.0 to 4.0 mg/L
4g Greater than 4.0 mg/L
5 Disinfection - Type
5a Type of disinfection system
5a 1) Chlorine (includes hypochlorite)
5a 2) Chloramines (ammonia + chlorine)
5a 3) Chlorine dioxide
5a 4) Ozone
5a 5) UV light
5a 6) Mixed oxidants
5b Type of secondary disinfectant if UV-light or ozone used as primary disinfectant
5b 1) Chlorine
5b 2) Chlorine dioxide
5b 3) Chloramines (ammonia + chlorine)
6 Disinfection - Facilities and Equipment
6a Sufficient capacity to meet all CT requirements and flow rates
6b Control of disinfectant feed rates
6b 1) Automatic control, flow proportional
6b 2) Automatic control, residual proportional
6b 3) Combination of 6b 1) and 6b 2)
6b 4) Manual control only
6c UV light disinfection (if it applies)
6c 1) Automatic flow rate control
6c 2) Complete back-up UV unit
6c 3) Automatic flow shut-down on loss of power
6c 4) Emergency power generator
6c 5) Back-up chlorinator if UV unit fails
6c 6) UV light dose measured and recorded
6c 7) UV units must be manually cleaned
6c 8) UV units incorporate automatic cleaning
6d Occurrences that frequently interrupt operation
6d 1) Power outage
6d 2) Equipment breakdown
6d 3) Lack of back-up equipment or spare parts
6d 4) Can water enter system if power outage occurs?
6d 4) a) Yes
6d 4) b) No
7 Disinfection System Monitoring and Alarms
7a Is disinfection system equipped with alarms?
7a 1) Yes
7a 2) No
7b Type of alarms that are triggered upon system failure
7b 1) Flashing light, horn, buzzer or other alarm indicator at facility
7b 2) Alarm sent to remote location or on-call person
8 Flow Rate Control - Treatment System
8a Flow rate control based on water demand
8b Constant, with on-off cycles
8c Flow rate controlled manually by operator
9 Treatment for corrosion control
9a Are chemicals added for corrosion control in distribution system?
9a 1) Yes
9a 2) No
9b Treatment system using chemical addition
9b 1) Adjust pH
9b 2) Phosphate, orthophosphate or polyphosphate
9b 3) Silica
9b 4) Adjust alkalinity using lime or soda ash
10 Turbidity monitoring/alarms
10a Is water from this source continuously monitored for turbidity?
(i.e., an in-line turbidimeter with a recording device)
10a 1) Yes
10a 2) No
10b Does the turbidimeter have a high level alarm
10b 1) Yes
10b 2) No
10c What type of high turbidity alarms are at this facility?
10c 1) Flashing light, horn, buzzer or other visual/audio indicator at treatment facility
10c 2) Alarm is sent to an operator via telemetry or telephone auto-dialer system
11 Cross-connections
11a All units have appropriate, approved backflow prevention devices
11b Do combined air-vacuum breaker valves and float valves for control of water levels exist?
11b 1) Yes, they exist
11b 2) No, none exist
11b 3) Are all float valves located before air-vacuum breaker valve?
11b 3) a) Yes
11b 3) b) No
11c Do safety shower/eye wash stations exist that are connected to treated water?
11c 1) Yes
11c 2) No
11c 3) Are approved backflow devices installed on supply line to safety shower/eye wash units?
11c 3) a) Yes
11c 3) b) No
11d Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
11d 1) Yes
11d 2) No
11e Do all hose bib connections have vacuum breaker attached?
11e 1) Yes
11e 2) No
11f Any connections to treated water for irrigation without backflow device installed?
11f 1) Yes
11f 2) No
Part C: Treatment
III. Ground W ater Supply – Disinfection/Corrosion Control Treatment Only III. Ground W ater Supply – Disinfection/Corrosion Control Treatment Only
No. 4 No. 4
Answer Item Item Description Comments –
2 Are disinfection/corrosion control only form of treatment?
2a Yes
2b No
3 Facility information
3a 1) Well Ground Water Source No.
3a 2) Well Ground Water Source No. (Value can be less than 100)
3a 3) Spring Ground Water Source No. Current Sum of %
3a 4) Spring Ground Water Source No. for All Treatment
3b Percent of annual supply Facilities = 0.0
4 Disinfection - Residual Concentration
4 Disinfectant concentration in water leaving treatment facilities
4a Less than 0.2 mg/L
4b 0.2 to 0.5 mg/L
4c 0.5 to 1.0 mg/L
4d 1.0 to 1.5 mg/L
4e 1.5 to 2.0 mg/L
4f 2.0 to 4.0 mg/L
4g Greater than 4.0 mg/L
5 Disinfection - Type
5a Type of disinfection system
5a 1) Chlorine (includes hypochlorite)
5a 2) Chloramines (ammonia + chlorine)
5a 3) Chlorine dioxide
5a 4) Ozone
5a 5) UV light
5a 6) Mixed oxidants
5b Type of secondary disinfectant if UV-light or ozone used as primary disinfectant
5b 1) Chlorine
5b 2) Chlorine dioxide
5b 3) Chloramines (ammonia + chlorine)
6 Disinfection - Facilities and Equipment
6a Sufficient capacity to meet all CT requirements and flow rates
6b Control of disinfectant feed rates
6b 1) Automatic control, flow proportional
6b 2) Automatic control, residual proportional
6b 3) Combination of 6b 1) and 6b 2)
6b 4) Manual control only
6c UV light disinfection (if it applies)
6c 1) Automatic flow rate control
8/7/2012
6c 2) Complete back-up UV unit
6c 3) Automatic flow shut-down on loss of power
6c 4) Emergency power generator
6c 5) Back-up chlorinator if UV unit fails
6c 6) UV light dose measured and recorded
6c 7) UV units must be manually cleaned
6c 8) UV units incorporate automatic cleaning
6d Occurrences that frequently interrupt operation
6d 1) Power outage
6d 2) Equipment breakdown
6d 3) Lack of back-up equipment or spare parts
6d 4) Can water enter system if power outage occurs?
6d 4) a) Yes
6d 4) b) No
7 Disinfection System Monitoring and Alarms
7a Is disinfection system equipped with alarms?
7a 1) Yes
7a 2) No
7b Type of alarms that are triggered upon system failure
7b 1) Flashing light, horn, buzzer or other alarm indicator at facility
7b 2) Alarm sent to remote location or on-call person
8 Flow Rate Control - Treatment System
8a Flow rate control based on water demand
8b Constant, with on-off cycles
8c Flow rate controlled manually by operator
9 Treatment for corrosion control
9a Are chemicals added for corrosion control in distribution system?
9a 1) Yes
9a 2) No
9b Treatment system using chemical addition
9b 1) Adjust pH
9b 2) Phosphate, orthophosphate or polyphosphate
9b 3) Silica
9b 4) Adjust alkalinity using lime or soda ash
10 Turbidity monitoring/alarms
10a Is water from this source continuously monitored for turbidity?
(i.e., an in-line turbidimeter with a recording device)
10a 1) Yes
10a 2) No
10b Does the turbidimeter have a high level alarm
10b 1) Yes
10b 2) No
10c What type of high turbidity alarms are at this facility?
10c 1) Flashing light, horn, buzzer or other visual/audio indicator at treatment facility
10c 2) Alarm is sent to an operator via telemetry or telephone auto-dialer system
11 Cross-connections
11a All units have appropriate, approved backflow prevention devices
11b Do combined air-vacuum breaker valves and float valves for control of water levels exist?
11b 1) Yes, they exist
11b 2) No, none exist
11b 3) Are all float valves located before air-vacuum breaker valve?
11b 3) a) Yes
11b 3) b) No
11c Do safety shower/eye wash stations exist that are connected to treated water?
11c 1) Yes
11c 2) No
11c 3) Are approved backflow devices installed on supply line to safety shower/eye wash units?
11c 3) a) Yes
11c 3) b) No
11d Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
11d 1) Yes
11d 2) No
11e Do all hose bib connections have vacuum breaker attached?
11e 1) Yes
11e 2) No
11f Any connections to treated water for irrigation without backflow device installed?
11f 1) Yes
11f 2) No
0 No. of Disinfection/Corrosion Control Treatment only Facilities for Ground Water Source(s)
0 Sum of Percent of Annual Supply for Disinfection/Corrosion Control Treatment only of Ground Water Source(s)
0 Sum of Percent of Annual Supply for All Treatment Facilities
100 Maximum Percent that can be Entered for No. 1
100 Maximum Percent that can be Entered for No. 2
100 Maximum Percent that can be Entered for No. 3
100 Maximum Percent that can be Entered for No. 4
8/7/2012
Part C: Treatment
IV. Ground Water Supply – Other Treatment Types
No. 1
Answer Item Item Description
2 Are disinfection/corrosion control only form of treatment?
2a Yes
2b No
3 Facility information
3a 1) Well Ground Water Source No.
3a 2) Well Ground Water Source No. (Value can be less than 100)
3a 3) Spring Ground Water Source No. Current Sum of %
3a 4) Spring Ground Water Source No. for All Treatment
3b Percent of annual supply Facilities = 0.0
4 Disinfection - Residual Concentration
4 Disinfectant concentration in water leaving treatment facilities
4a Less than 0.2 mg/L
4b 0.2 to 0.5 mg/L
4c 0.5 to 1.0 mg/L
4d 1.0 to 1.5 mg/L
4e 1.5 to 2.0 mg/L
4f 2.0 to 4.0 mg/L
4g Greater than 4.0 mg/L
5 Disinfection - Type
5a Type of disinfection system
5a 1) Chlorine (includes hypochlorite)
5a 2) Chloramines (ammonia + chlorine)
5a 3) Chlorine dioxide
5a 4) Ozone
5a 5) UV light
5a 6) Mixed oxidants
5b Type of secondary disinfectant if UV-light or ozone used as primary disinfectant
5b 1) Chlorine
5b 2) Chlorine dioxide
5b 3) Chloramines (ammonia + chlorine)
6 Disinfection - Facilities and Equipment
6a Sufficient capacity to meet all CxT or UV-dose requirements at all flow rates
6b Control of disinfectant feed rates
6b 1) Automatic control, flow proportional
6b 2) Automatic control, residual proportional
6b 3) Combination of 6b 1) and 6b 2)
6b 4) Manual control only
6c UV light disinfection (if it applies)
6c 1) Automatic flow rate control
6c 2) Complete back-up UV unit
6c 3) Automatic flow shut-down on loss of power
6c 4) Emergency power generator
6c 5) Back-up chlorinator if UV unit fails
6c 6) UV light dose measured and recorded
6c 7) UV units must be manually cleaned
6c 8) UV units incorporate automatic cleaning
6d Occurrences that frequently interrupt operation
6d 1) Power outage
6d 2) Equipment breakdown
6d 3) Lack of back-up equipment or spare parts
6d 4) Can water enter system if power outage occurs?
6d 4) a) Yes
6d 4) b) No
7 Disinfection System Monitoring and Alarms
7a Is disinfection system equipped with alarms?
7a 1) Yes
7a 2) No
7b Type of alarms that are triggered upon system failure
7b 1) Flashing light, horn, buzzer or other alarm indicator at facility
7b 2) Alarm sent to remote location or on-call person
8 Flow Rate Control - Treatment System
8a Flow rate control based on water demand
8b Constant, with on-off cycles
8c Flow rate controlled manually by operator
9 Corrosion control treatment
9a Are chemicals added for corrosion control in distribution system?
9a 1) Yes
9a 2) No
9b Treatment system using chemical addition
9b 1) Adjust pH
9b 2) Phosphate, orthophosphate or polyphosphate
9b 3) Silica
9b 4) Adjust alkalinity using lime or soda ash
10 Turbidity monitoring/alarms
10a Is water from this source continuously monitored for turbidity?
(i.e., an in-line turbidimeter with a recording device)
10a 1) Yes
10a 2) No
10b Does the turbidimeter have a high level alarm
10b 1) Yes
10b 2) No
10c What type of high turbidity alarms are at this facility?
10c 1) Flashing light, horn, buzzer or other visual/audio indicator at treatment facility
10c 2) Alarm is sent to an operator via telemetry or telephone auto-dialer system
11 Filtration treatment
11a No filtration treatment for this ground water source
11b Granular media filtration
11c Granular activated carbon
11d Cartridge or bag filters
11e Ion exchange units
11f Membrane filtration
11f 1) Not sure of membrane type
11f 2) Reverse osmosis
11f 3) Nanofiltration
11f 4) Ultrafiltration
11f 5) Microfiltration
12 Aeration or air stripping
12a System does not include aeration or air stripping treatment
12b Tray aeration
12c Packed tower aeration or air stripping
12d Shallow basin aeration
12e Cascade aeration
12f Type of air filters
12f 1) No filters or screens
12f 2) Screens only
12f 3) Dust and insect removal filters
12g Is there a system to clean and disinfect air contacting surfaces or packed media?
12g 1) Yes
12g 2) No
13 Cross-connections
13a All units have appropriate, approved backflow prevention devices
13b Do combined air-vacuum breaker valves and float valves for control of water levels exist?
13b 1) Yes, they exist
13b 2) No, none exist
13b 3) Are all float valves located before air-vacuum breaker valve?
13b 3) a) Yes
13b 3) b) No
13c Do safety shower/eye wash stations exist that are connected to treated water?
13c 1) Yes
13c 2) No
13c 3) Are approved backflow devices installed on supply line to safety shower/eye wash units?
13c 3) a) Yes
13c 3) b) No
13d Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
13d 1) Yes
13d 2) No
13e Do all hose bib connections have vacuum breaker attached?
13e 1) Yes
13e 2) No
13f Any connections to treated water for irrigation without backflow device installed?
13f 1) Yes
13f 2) No
Part C: Treatment
IV. Ground Water Supply – Other Treatment Types
No. 2
Answer Item Item Description
2 Are disinfection/corrosion control only form of treatment?
2a Yes
2b No
3 Facility information
3a 1) Well Ground Water Source No.
3a 2) Well Ground Water Source No. (Value can be less than 100)
3a 3) Spring Ground Water Source No. Current Sum of %
3a 4) Spring Ground Water Source No. for All Treatment
3b Percent of annual supply Facilities = 0.0
4 Disinfection - Residual Concentration
4 Disinfectant concentration in water leaving treatment facilities
4a Less than 0.2 mg/L
4b 0.2 to 0.5 mg/L
4c 0.5 to 1.0 mg/L
4d 1.0 to 1.5 mg/L
4e 1.5 to 2.0 mg/L
4f 2.0 to 4.0 mg/L
4g Greater than 4.0 mg/L
5 Disinfection - Type
5a Type of disinfection system
5a 1) Chlorine (includes hypochlorite)
5a 2) Chloramines (ammonia + chlorine)
5a 3) Chlorine dioxide
5a 4) Ozone
5a 5) UV light
5a 6) Mixed oxidants
5b Type of secondary disinfectant if UV-light or ozone used as primary disinfectant
5b 1) Chlorine
5b 2) Chlorine dioxide
5b 3) Chloramines (ammonia + chlorine)
6 Disinfection - Facilities and Equipment
6a Sufficient capacity to meet all CxT or UV-dose requirements at all flow rates
6b Control of disinfectant feed rates
6b 1) Automatic control, flow proportional
6b 2) Automatic control, residual proportional
6b 3) Combination of 6b 1) and 6b 2)
6b 4) Manual control only
6c UV light disinfection (if it applies)
6c 1) Automatic flow rate control
6c 2) Complete back-up UV unit
6c 3) Automatic flow shut-down on loss of power
6c 4) Emergency power generator
6c 5) Back-up chlorinator if UV unit fails
6c 6) UV light dose measured and recorded
6c 7) UV units must be manually cleaned
6c 8) UV units incorporate automatic cleaning
6d Occurrences that frequently interrupt operation
6d 1) Power outage
6d 2) Equipment breakdown
6d 3) Lack of back-up equipment or spare parts
6d 4) Can water enter system if power outage occurs?
Yes
6d 4) a)
No
6d 4) b)
7 Disinfection System Monitoring and Alarms
7a Is disinfection system equipped with alarms?
7a 1) Yes
7a 2) No
7b Type of alarms that are triggered upon system failure
7b 1) Flashing light, horn, buzzer or other alarm indicator at facility
7b 2) Alarm sent to remote location or on-call person
8 Flow Rate Control - Treatment System
8a Flow rate control based on water demand
8b Constant, with on-off cycles
8c Flow rate controlled manually by operator
9 Corrosion control treatment
9a Are chemicals added for corrosion control in distribution system?
9a 1) Yes
9a 2) No
9b Treatment system using chemical addition
9b 1) Adjust pH
9b 2) Phosphate, orthophosphate or polyphosphate
9b 3) Silica
9b 4) Adjust alkalinity using lime or soda ash
10 Turbidity monitoring/alarms
10a Is water from this source continuously monitored for turbidity?
(i.e., an in-line turbidimeter with a recording device)
10a 1) Yes
10a 2) No
10b Does the turbidimeter have a high level alarm
10b 1) Yes
10b 2) No
10c What type of high turbidity alarms are at this facility?
10c 1) Flashing light, horn, buzzer or other visual/audio indicator at treatment facility
10c 2) Alarm is sent to an operator via telemetry or telephone auto-dialer system
11 Filtration treatment
11a No filtration treatment for this ground water source
11b Granular media filtration
11c Granular activated carbon
11d Cartridge or bag filters
11e Ion exchange units
11f Membrane filtration
11f 1) Not sure of membrane type
11f 2) Reverse osmosis
11f 3) Nanofiltration
11f 4) Ultrafiltration
11f 5) Microfiltration
12 Aeration or air stripping
12a System does not include aeration or air stripping treatment
12b Tray aeration
12c Packed tower aeration or air stripping
12d Shallow basin aeration
12e Cascade aeration
12f Type of air filters
12f 1) No filters or screens
12f 2) Screens only
12f 3) Dust and insect removal filters
12g Is there a system to clean and disinfect air contacting surfaces or packed media?
12g 1) Yes
12g 2) No
13 Cross-connections
13a All units have appropriate, approved backflow prevention devices
13b Do combined air-vacuum breaker valves and float valves for control of water levels exist?
13b 1) Yes, they exist
13b 2) No, none exist
13b 3) Are all float valves located before air-vacuum breaker valve?
13b 3) a) Yes
13b 3) b) No
13c Do safety shower/eye wash stations exist that are connected to treated water?
13c 1) Yes
13c 2) No
13c 3) Are approved backflow devices installed on supply line to safety shower/eye wash units?
13c 3) a) Yes
13c 3) b) No
13d Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
13d 1) Yes
13d 2) No
13e Do all hose bib connections have vacuum breaker attached?
13e 1) Yes
13e 2) No
13f Any connections to treated water for irrigation without backflow device installed?
13f 1) Yes
13f 2) No
Part C: Treatment
IV. Ground Water Supply – Other Treatment Types
No. 3
Answer Item Item Description
2 Are disinfection/corrosion control only form of treatment?
2a Yes
2b No
3 Facility information
3a 1) Well Ground Water Source No.
3a 2) Well Ground Water Source No. (Value can be less than 100)
3a 3) Spring Ground Water Source No. Current Sum of %
3a 4) Spring Ground Water Source No. for All Treatment
3b Percent of annual supply Facilities = 0.0
4 Disinfection - Residual Concentration
4 Disinfectant concentration in water leaving treatment facilities
4a Less than 0.2 mg/L
4b 0.2 to 0.5 mg/L
4c 0.5 to 1.0 mg/L
4d 1.0 to 1.5 mg/L
4e 1.5 to 2.0 mg/L
4f 2.0 to 4.0 mg/L
4g Greater than 4.0 mg/L
5 Disinfection - Type
5a Type of disinfection system
5a 1) Chlorine (includes hypochlorite)
5a 2) Chloramines (ammonia + chlorine)
5a 3) Chlorine dioxide
5a 4) Ozone
5a 5) UV light
5a 6) Mixed oxidants
5b Type of secondary disinfectant if UV-light or ozone used as primary disinfectant
5b 1) Chlorine
5b 2) Chlorine dioxide
5b 3) Chloramines (ammonia + chlorine)
6 Disinfection - Facilities and Equipment
6a Sufficient capacity to meet all CxT or UV-dose requirements at all flow rates
6b Control of disinfectant feed rates
6b 1) Automatic control, flow proportional
6b 2) Automatic control, residual proportional
6b 3) Combination of 6b 1) and 6b 2)
6b 4) Manual control only
6c UV light disinfection (if it applies)
6c 1) Automatic flow rate control
6c 2) Complete back-up UV unit
6c 3) Automatic flow shut-down on loss of power
6c 4) Emergency power generator
6c 5) Back-up chlorinator if UV unit fails
6c 6) UV light dose measured and recorded
6c 7) UV units must be manually cleaned
6c 8) UV units incorporate automatic cleaning
6d Occurrences that frequently interrupt operation
6d 1) Power outage
6d 2) Equipment breakdown
6d 3) Lack of back-up equipment or spare parts
6d 4) Can water enter system if power outage occurs?
6d 4) a) Yes
6d 4) b) No
7 Disinfection System Monitoring and Alarms
7a Is disinfection system equipped with alarms?
7a 1) Yes
7a 2) No
7b Type of alarms that are triggered upon system failure
7b 1) Flashing light, horn, buzzer or other alarm indicator at facility
7b 2) Alarm sent to remote location or on-call person
8 Flow Rate Control - Treatment System
8a Flow rate control based on water demand
8b Constant, with on-off cycles
8c Flow rate controlled manually by operator
9 Corrosion control treatment
9a Are chemicals added for corrosion control in distribution system?
9a 1) Yes
9a 2) No
9b Treatment system using chemical addition
9b 1) Adjust pH
9b 2) Phosphate, orthophosphate or polyphosphate
9b 3) Silica
9b 4) Adjust alkalinity using lime or soda ash
10 Turbidity monitoring/alarms
10a Is water from this source continuously monitored for turbidity?
(i.e., an in-line turbidimeter with a recording device)
10a 1) Yes
10a 2) No
10b Does the turbidimeter have a high level alarm
10b 1) Yes
10b 2) No
10c What type of high turbidity alarms are at this facility?
10c 1) Flashing light, horn, buzzer or other visual/audio indicator at treatment facility
10c 2) Alarm is sent to an operator via telemetry or telephone auto-dialer system
11 Filtration treatment
11a No filtration treatment for this ground water source
11b Granular media filtration
11c Granular activated carbon
11d Cartridge or bag filters
11e Ion exchange units
11f Membrane filtration
11f 1) Not sure of membrane type
11f 2) Reverse osmosis
11f 3) Nanofiltration
11f 4) Ultrafiltration
11f 5) Microfiltration
12 Aeration or air stripping
12a System does not include aeration or air stripping treatment
12b Tray aeration
12c Packed tower aeration or air stripping
12d Shallow basin aeration
12e Cascade aeration
12f Type of air filters
12f 1) No filters or screens
12f 2) Screens only
12f 3) Dust and insect removal filters
12g Is there a system to clean and disinfect air contacting surfaces or packed media?
12g 1) Yes
12g 2) No
13 Cross-connections
13a All units have appropriate, approved backflow prevention devices
13b Do combined air-vacuum breaker valves and float valves for control of water levels exist?
13b 1) Yes, they exist
13b 2) No, none exist
13b 3) Are all float valves located before air-vacuum breaker valve?
13b 3) a) Yes
13b 3) b) No
13c Do safety shower/eye wash stations exist that are connected to treated water?
13c 1) Yes
13c 2) No
13c 3) Are approved backflow devices installed on supply line to safety shower/eye wash units?
13c 3) a) Yes
13c 3) b) No
13d Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
13d 1) Yes
13d 2) No
13e Do all hose bib connections have vacuum breaker attached?
13e 1) Yes
13e 2) No
13f Any connections to treated water for irrigation without backflow device installed?
13f 1) Yes
13f 2) No
Part C: Treatment
IV. Ground Water Supply – Other Treatment Types
No. 4
Answer Item Item Description
2 Are disinfection/corrosion control only form of treatment?
2a Yes
2b No
3 Facility information
3a 1) Well Ground Water Source No.
3a 2) Well Ground Water Source No. (Value can be less than 100)
3a 3) Spring Ground Water Source No. Current Sum of %
3a 4) Spring Ground Water Source No. for All Treatment
3b Percent of annual supply Facilities = 0.0
4 Disinfection - Residual Concentration
4 Disinfectant concentration in water leaving treatment facilities
4a Less than 0.2 mg/L
4b 0.2 to 0.5 mg/L
4c 0.5 to 1.0 mg/L
4d 1.0 to 1.5 mg/L
4e 1.5 to 2.0 mg/L
4f 2.0 to 4.0 mg/L
4g Greater than 4.0 mg/L
5 Disinfection - Type
5a Type of disinfection system
5a 1) Chlorine (includes hypochlorite)
5a 2) Chloramines (ammonia + chlorine)
5a 3) Chlorine dioxide
5a 4) Ozone
5a 5) UV light
5a 6) Mixed oxidants
5b Type of secondary disinfectant if UV-light or ozone used as primary disinfectant
5b 1) Chlorine
5b 2) Chlorine dioxide
5b 3) Chloramines (ammonia + chlorine)
6 Disinfection - Facilities and Equipment
6a Sufficient capacity to meet all CxT or UV-dose requirements at all flow rates
6b Control of disinfectant feed rates
6b 1) Automatic control, flow proportional
6b 2) Automatic control, residual proportional
6b 3) Combination of 6b 1) and 6b 2)
6b 4) Manual control only
6c UV light disinfection (if it applies)
6c 1) Automatic flow rate control
6c 2) Complete back-up UV unit
6c 3) Automatic flow shut-down on loss of power
6c 4) Emergency power generator
6c 5) Back-up chlorinator if UV unit fails
6c 6) UV light dose measured and recorded
6c 7) UV units must be manually cleaned
6c 8) UV units incorporate automatic cleaning
6d Occurrences that frequently interrupt operation
6d 1) Power outage
6d 2) Equipment breakdown
6d 3) Lack of back-up equipment or spare parts
6d 4) Can water enter system if power outage occurs?
Yes
6d 4) a)
No
6d 4) b)
7 Disinfection System Monitoring and Alarms
7a Is disinfection system equipped with alarms?
7a 1) Yes
7a 2) No
7b Type of alarms that are triggered upon system failure
7b 1) Flashing light, horn, buzzer or other alarm indicator at facility
7b 2) Alarm sent to remote location or on-call person
8 Flow Rate Control - Treatment System
8a Flow rate control based on water demand
8b Constant, with on-off cycles
8c Flow rate controlled manually by operator
9 Corrosion control treatment
9a Are chemicals added for corrosion control in distribution system?
9a 1) Yes
9a 2) No
9b Treatment system using chemical addition
9b 1) Adjust pH
9b 2) Phosphate, orthophosphate or polyphosphate
9b 3) Silica
9b 4) Adjust alkalinity using lime or soda ash
10 Turbidity monitoring/alarms
10a Is water from this source continuously monitored for turbidity?
(i.e., an in-line turbidimeter with a recording device)
10a 1) Yes
10a 2) No
10b Does the turbidimeter have a high level alarm
10b 1) Yes
10b 2) No
10c What type of high turbidity alarms are at this facility?
10c 1) Flashing light, horn, buzzer or other visual/audio indicator at treatment facility
10c 2) Alarm is sent to an operator via telemetry or telephone auto-dialer system
11 Filtration treatment
11a No filtration treatment for this ground water source
11b Granular media filtration
11c Granular activated carbon
11d Cartridge or bag filters
11e Ion exchange units
11f Membrane filtration
11f 1) Not sure of membrane type
11f 2) Reverse osmosis
11f 3) Nanofiltration
11f 4) Ultrafiltration
11f 5) Microfiltration
12 Aeration or air stripping
12a System does not include aeration or air stripping treatment
12b Tray aeration
12c Packed tower aeration or air stripping
12d Shallow basin aeration
12e Cascade aeration
12f Type of air filters
12f 1) No filters or screens
12f 2) Screens only
12f 3) Dust and insect removal filters
12g Is there a system to clean and disinfect air contacting surfaces or packed media?
12g 1) Yes
12g 2) No
13 Cross-connections
13a All units have appropriate, approved backflow prevention devices
13b Do combined air-vacuum breaker valves and float valves for control of water levels exist?
13b 1) Yes, they exist
13b 2) No, none exist
13b 3) Are all float valves located before air-vacuum breaker valve?
13b 3) a) Yes
13b 3) b) No
13c Do safety shower/eye wash stations exist that are connected to treated water?
13c 1) Yes
13c 2) No
13c 3) Are approved backflow devices installed on supply line to safety shower/eye wash units?
13c 3) a) Yes
13c 3) b) No
13d Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
13d 1) Yes
13d 2) No
13e Do all hose bib connections have vacuum breaker attached?
13e 1) Yes
13e 2) No
13f Any connections to treated water for irrigation without backflow device installed?
13f 1) Yes
13f 2) No
0 No. of Filtration/Disinfection/Corrosion Control or Other Treatment Types for Ground Water Source(s)
0 Sum of Percent of Annual Supply for Filtration/Disinfection/Corrosion Control or Other Treatment Types for Ground Water Sourc
0 Sum of Percent of Annual Supply for All Treatment Facilities
100 Maximum Percent that can be Entered for No. 1
100 Maximum Percent that can be Entered for No. 2
100 Maximum Percent that can be Entered for No. 3
100 Maximum Percent that can be Entered for No. 4
IV. Ground Water Supply – Other Treatment Types
No. 1
Comments –
IV. Ground Water Supply – Other Treatment Types
No. 2
Comments –
IV. Ground Water Supply – Other Treatment Types
No. 3
Comments –
IV. Ground Water Supply – Other Treatment Types
No. 4
Comments –
No. 2
Treatment Types for Ground Water Source(s)
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
No. 4
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
Part D: Pumping and Storage
I. Pumping Facilities I. Pumping Facilities
No. 1 No. 1
Answer Item Item Description Comments –
1 Does your system hav e pumping facilities?
1a Yes Current Sum of % for This Type of Facility
1b No 0.0
2 Pumping Facility Information Value must be less than or equal to 100%
2a Percent of annual water requirements pumped by this facility, %
2b If pumping facility is associated with treatment facility, indicate treatment facility number
2b 1) Number designation for treatment plant
2b 2) Number designation for well
2b 3) Number designation for spring or infiltration gallery
2b 4) Number designation for lake intake
2b 5) Number designation for surface water intake
2b 6) Facility is associated with none of the above
3 Type of pumping facility
3a Distribution system booster pump
3b Well pump, submersible
3c Well pump, above ground vertical turbine
3d Treated water, finished potable water
3e Raw, untreated water pump station
4 Pump station capacity
4a Back-up pump is installed
4b Loss of pump facility would totally eliminate water supply
4c Does facility have adequate capacity for all water demands
4c 1) Yes
4c 2) No
5 Emergency pow er prov isions
5a Facility has emergency power provisions
5b Emergency power units tested regularly
6 Physical facility
6a Discharge line has check valve
6b Intake and discharge lines have isolation valves
6c Submersible-type well pump, installed with a pitless adaptor
6d Pressure gauge on discharge line
6e Pump control during start-up and shut-down of pump
6e 1) Variable speed motor or drive
6e 2) Each pump discharge line has a pump control valve
6f Located in below ground structure
6g This is a well pump equipped with blow-off valve and blow-off line
6g 1) Blow-off line discharges to atmosphere
6g 2) Blow-off line discharges back down well casing
6g 3) Blow-off line is screened, capped or equipped with a check or flap valve
7 Potential cross-connections
7a Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
7a 1) Yes
7a 2) No
7b Do all hose bib connections have vacuum breaker attached?
7b 1) Yes
7b 2) No
7c Any connections to treated water for irrigation without backflow device installed?
7c 1) Yes
7c 2) No
7d Do all seal water/pump priming lines have approved backflow prevention devices?
7d 1) Yes
7d 2) No
8 Susceptibility to runoff or flooding
Is pump station susceptible to flooding or surface runoff?
8a Yes
8b No
9 Control of pumps
9a Not sure how pumps controlled
9b Control of pumps can be easily changed by operator
9b 1) Yes, can be easily changed
9b 2) No
10 Maintenance and Repairs
10a All maintenance/repairs by system operators
10b Major maintenance/repairs by outside contractors
10c Outside maintenance contractors have proper training for potable water systems (disinfection knowledge)
10d Water system operator monitors all disinfection and testing
Part D: Pumping and Storage
I. Pumping Facilities I. Pumping Facilities
No. 2 No. 2
Answer Item Item Description Comments –
1 Does your system hav e pumping facilities?
1a Yes Current Sum of % for This Type of Facility
1b No 0.0
2 Pumping Facility Information Value must be less than or equal to 100%
2a Percent of annual water requirements pumped by this facility, %
2b If pumping facility is associated with treatment facility, indicate treatment facility number
2b 1) Number designation for treatment plant
2b 2) Number designation for well
2b 3) Number designation for spring or infiltration gallery
2b 4) Number designation for lake intake
2b 5) Number designation for surface water intake
2b 6) Facility is associated with none of the above
3 Type of pumping facility
3a Distribution system booster pump
3b Well pump, submersible
3c Well pump, above ground vertical turbine
3d Treated water, finished potable water
3e Raw, untreated water pump station
4 Pump station capacity
4a Back-up pump is installed
4b Loss of pump facility would totally eliminate water supply
4c Does facility have adequate capacity for all water demands
4c 1) Yes
4c 2) No
5 Emergency pow er prov isions
5a Facility has emergency power provisions
5b Emergency power units tested regularly
6 Physical facility
6a Discharge line has check valve
6b Intake and discharge lines have isolation valves
6c Submersible-type well pump, installed with a pitless adaptor
6d Pressure gauge on discharge line
6e Pump control during start-up and shut-down of pump
6e 1) Variable speed motor or drive
6e 2) Each pump discharge line has a pump control valve
6f Located in below ground structure
6g This is a well pump equipped with blow-off valve and blow-off line
6g 1) Blow-off line discharges to atmosphere
6g 2) Blow-off line discharges back down well casing
6g 3) Blow-off line is screened, capped or equipped with a check or flap valve
7 Potential cross-connections
7a Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
7a 1) Yes
7a 2) No
7b Do all hose bib connections have vacuum breaker attached?
7b 1) Yes
7b 2) No
7c Any connections to treated water for irrigation without backflow device installed?
7c 1) Yes
7c 2) No
7d Do all seal water/pump priming lines have approved backflow prevention devices?
7d 1) Yes
7d 2) No
8 Susceptibility to runoff or flooding
Is pump station susceptible to flooding or surface runoff?
8a Yes
8b No
9 Control of pumps
9a Not sure how pumps controlled
9b Control of pumps can be easily changed by operator
9b 1) Yes, can be easily changed
9b 2) No
10 Maintenance and Repairs
10a All maintenance/repairs by system operators
10b Major maintenance/repairs by outside contractors
10c Outside maintenance contractors have proper training for potable water systems (disinfection knowledge)
10d Water system operator monitors all disinfection and testing
Part D: Pumping and Storage
I. Pumping Facilities I. Pumping Facilities
No. 3 No. 3
Answer Item Item Description Comments –
1 Does your system hav e pumping facilities?
1a Yes Current Sum of % for This Type of Facility
1b No 0.0
2 Pumping Facility Information Value must be less than or equal to 100%
2a Percent of annual water requirements pumped by this facility, %
2b If pumping facility is associated with treatment facility, indicate treatment facility number
2b 1) Number designation for treatment plant
2b 2) Number designation for well
2b 3) Number designation for spring or infiltration gallery
2b 4) Number designation for lake intake
2b 5) Number designation for surface water intake
2b 6) Facility is associated with none of the above
3 Type of pumping facility
3a Distribution system booster pump
3b Well pump, submersible
3c Well pump, above ground vertical turbine
3d Treated water, finished potable water
3e Raw, untreated water pump station
4 Pump station capacity
4a Back-up pump is installed
4b Loss of pump facility would totally eliminate water supply
4c Does facility have adequate capacity for all water demands
4c 1) Yes
4c 2) No
5 Emergency pow er prov isions
5a Facility has emergency power provisions
5b Emergency power units tested regularly
6 Physical facility
6a Discharge line has check valve
6b Intake and discharge lines have isolation valves
6c Submersible-type well pump, installed with a pitless adaptor
6d Pressure gauge on discharge line
6e Pump control during start-up and shut-down of pump
6e 1) Variable speed motor or drive
6e 2) Each pump discharge line has a pump control valve
6f Located in below ground structure
6g This is a well pump equipped with blow-off valve and blow-off line
6g 1) Blow-off line discharges to atmosphere
6g 2) Blow-off line discharges back down well casing
6g 3) Blow-off line is screened, capped or equipped with a check or flap valve
7 Potential cross-connections
7a Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
7a 1) Yes
7a 2) No
7b Do all hose bib connections have vacuum breaker attached?
7b 1) Yes
7b 2) No
7c Any connections to treated water for irrigation without backflow device installed?
7c 1) Yes
7c 2) No
7d Do all seal water/pump priming lines have approved backflow prevention devices?
7d 1) Yes
7d 2) No
8 Susceptibility to runoff or flooding
Is pump station susceptible to flooding or surface runoff?
8a Yes
8b No
9 Control of pumps
9a Not sure how pumps controlled
9b Control of pumps can be easily changed by operator
9b 1) Yes, can be easily changed
9b 2) No
10 Maintenance and Repairs
10a All maintenance/repairs by system operators
10b Major maintenance/repairs by outside contractors
10c Outside maintenance contractors have proper training for potable water systems (disinfection knowledge)
10d Water system operator monitors all disinfection and testing
Part D: Pumping and Storage
I. Pumping Facilities I. Pumping Facilities
No. 4 No. 4
Answer Item Item Description Comments –
1 Does your system hav e pumping facilities?
1a Yes Current Sum of % for This Type of Facility
1b No 0.0
2 Pumping Facility Information Value must be less than or equal to 100%
2a Percent of annual water requirements pumped by this facility, %
2b If pumping facility is associated with treatment facility, indicate treatment facility number
2b 1) Number designation for treatment plant
2b 2) Number designation for well
2b 3) Number designation for spring or infiltration gallery
2b 4) Number designation for lake intake
2b 5) Number designation for surface water intake
2b 6) Facility is associated with none of the above
3 Type of pumping facility
3a Distribution system booster pump
3b Well pump, submersible
3c Well pump, above ground vertical turbine
3d Treated water, finished potable water
3e Raw, untreated water pump station
4 Pump station capacity
4a Back-up pump is installed
4b Loss of pump facility would totally eliminate water supply
4c Does facility have adequate capacity for all water demands
4c 1) Yes
4c 2) No
5 Emergency pow er prov isions
5a Facility has emergency power provisions
5b Emergency power units tested regularly
6 Physical facility
6a Discharge line has check valve
6b Intake and discharge lines have isolation valves
6c Submersible-type well pump, installed with a pitless adaptor
6d Pressure gauge on discharge line
6e Pump control during start-up and shut-down of pump
6e 1) Variable speed motor or drive
6e 2) Each pump discharge line has a pump control valve
6f Located in below ground structure
6g This is a well pump equipped with blow-off valve and blow-off line
6g 1) Blow-off line discharges to atmosphere
6g 2) Blow-off line discharges back down well casing
6g 3) Blow-off line is screened, capped or equipped with a check or flap valve
7 Potential cross-connections
7a Any drain lines from valves or equipment that terminate below rim of drain or onto floor?
7a 1) Yes
7a 2) No
7b Do all hose bib connections have vacuum breaker attached?
7b 1) Yes
7b 2) No
7c Any connections to treated water for irrigation without backflow device installed?
7c 1) Yes
7c 2) No
7d Do all seal water/pump priming lines have approved backflow prevention devices?
7d 1) Yes
7d 2) No
8 Susceptibility to runoff or flooding
Is pump station susceptible to flooding or surface runoff?
8a Yes
8b No
9 Control of pumps
9a Not sure how pumps controlled
9b Control of pumps can be easily changed by operator
9b 1) Yes, can be easily changed
9b 2) No
10 Maintenance and Repairs
10a All maintenance/repairs by system operators
10b Major maintenance/repairs by outside contractors
10c Outside maintenance contractors have proper training for potable water systems (disinfection knowledge)
10d Water system operator monitors all disinfection and testing
8/7/2012
Part D: Pumping and Storage
II. Storage Facilities
No. 1
Answer Item Item Description
1 Does your system have storage facilities?
1a Yes (Final value should equal 100)
1b No Current Sum of %
2 Storage facility information for All Storage
2 Percent of system's total water storage capacity, % Facilities = 0.0
3 Type of storage facility
3a Ground level, steel, concrete, or fiberglass
3b Elevated, steel or concrete
3c Buried, concrete, steel or fiberglass
3c 1) Tank partially buried
3c 2) Completely buried, soil over top
3c 3) Ground water drainage system in-place and working
3d Hydropneumatic tanks
3d 1) Internal bladder type
3d 2) Tank has no bladder, air contacts water
4 Holes in roof, walls or door; tank cover
4a Is tank uncovered (no roof)?
4a 1) Yes
4a 2) No
4b Does tank have open holes in roof, walls, joints or access doors?
4b 1) Yes
4b 2) No
5 Air vents
5a Does this tank have air vents?
5a 1) Yes
5a 2) No
5b Are vents tightly screened to prevent insects, rodents and birds from entering?
5b 1) Yes
5b 2) No
5c Are air vents constructed to prevent rain from entering tank?
5c 1) Yes
5c 2) No
6 Access openings
6a Does tank have access openings?
6a 1) Yes
6a 2) No
6b Access opening(s) installed on raised curb
6c Access opening has tight, sanitary door, can be opened without contaminating water
6d Vandalism-proof security locks
6e Manhole type covers are used for access doors
6f If they exist, do manhole covers have holes?
6f 1) Yes, manhole covers have holes
6f 2) No, no holes in manhole covers
7 Is tank site susceptible to runoff or flooding?
7a Yes
7b No
8 Tank overflow/drain lines
8a Discharge to atmosphere, 12-in or more above ground, do not become submerged
8b End of lines screened or have tight-flap-gate
9 Storage capacity
9a Tank can be totally drawn down (emptied) during peak demands
9b Excessive storage capacity
10 Storage controls
10a Water level/pressure controls manually set, difficult or impossible to change
10b Easily changed by operator
10c Levels are managed to minimize water age in tank
11 Tank maintenance
11a Easily isolated with valves for cleaning/maintenance
11b Tank inspected and repaired at least once every 5 years
11c Tank is steel and interior is in need of repair or painting
11d Tank is concrete, has visible cracks or concrete spalling in need of repair
12 Tank cleaning
12a How frequently is tank cleaned?
12a 1) Once every year
12a 2) Every two years
12a 3) Three to Five years
12a 4) Greater than Five years
12b Tank never drained, cleaned and inspected
12c When tank drained and cleaned, strict disinfection procedures used
Part D: Pumping and Storage
II. Storage Facilities
No. 2
Answer Item Item Description
1 Does your system have storage facilities?
1a Yes (Final value should equal 100)
1b No Current Sum of %
2 Storage facility information for All Storage
2 Percent of system's total water storage capacity, % Facilities = 0.0
3 Type of storage facility
3a Ground level, steel, concrete, or fiberglass
3b Elevated, steel or concrete
3c Buried, concrete, steel or fiberglass
3c 1) Tank partially buried
3c 2) Completely buried, soil over top
3c 3) Ground water drainage system in-place and working
3d Hydropneumatic tanks
3d 1) Internal bladder type
3d 2) Tank has no bladder, air contacts water
4 Holes in roof, walls or door; tank cover
4a Is tank uncovered (no roof)?
4a 1) Yes
4a 2) No
4b Does tank have open holes in roof, walls, joints or access doors?
4b 1) Yes
4b 2) No
5 Air vents
5a Does this tank have air vents?
5a 1) Yes
5a 2) No
5b Are vents tightly screened to prevent insects, rodents and birds from entering?
5b 1) Yes
5b 2) No
5c Are air vents constructed to prevent rain from entering tank?
5c 1) Yes
5c 2) No
6 Access openings
6a Does tank have access openings?
6a 1) Yes
6a 2) No
6b Access opening(s) installed on raised curb
6c Access opening has tight, sanitary door, can be opened without contaminating water
6d Vandalism-proof security locks
6e Manhole type covers are used for access doors
6f If they exist, do manhole covers have holes?
6f 1) Yes, manhole covers have holes
6f 2) No, no holes in manhole covers
7 Is tank site susceptible to runoff or flooding?
7a Yes
7b No
8 Tank overflow/drain lines
8a Discharge to atmosphere, 12-in or more above ground, do not become submerged
8b End of lines screened or have tight-flap-gate
9 Storage capacity
9a Tank can be totally drawn down (emptied) during peak demands
9b Excessive storage capacity
10 Storage controls
10a Water level/pressure controls manually set, difficult or impossible to change
10b Easily changed by operator
10c Levels are managed to minimize water age in tank
11 Tank maintenance
11a Easily isolated with valves for cleaning/maintenance
11b Tank inspected and repaired at least once every 5 years
11c Tank is steel and interior is in need of repair or painting
11d Tank is concrete, has visible cracks or concrete spalling in need of repair
12 Tank cleaning
12a How frequently is tank cleaned?
12a 1) Once every year
12a 2) Every two years
12a 3) Three to Five years
12a 4) Greater than Five years
12b Tank never drained, cleaned and inspected
12c When tank drained and cleaned, strict disinfection procedures used
Part D: Pumping and Storage
II. Storage Facilities
No. 3
Answer Item Item Description
1 Does your system have storage facilities?
1a Yes (Final value should equal 100)
1b No Current Sum of %
2 Storage facility information for All Storage
2 Percent of system's total water storage capacity, % Facilities = 0.0
3 Type of storage facility
3a Ground level, steel, concrete, or fiberglass
3b Elevated, steel or concrete
3c Buried, concrete, steel or fiberglass
3c 1) Tank partially buried
3c 2) Completely buried, soil over top
3c 3) Ground water drainage system in-place and working
3d Hydropneumatic tanks
3d 1) Internal bladder type
3d 2) Tank has no bladder, air contacts water
4 Holes in roof, walls or door; tank cover
4a Is tank uncovered (no roof)?
4a 1) Yes
4a 2) No
4b Does tank have open holes in roof, walls, joints or access doors?
4b 1) Yes
4b 2) No
5 Air vents
5a Does this tank have air vents?
5a 1) Yes
5a 2) No
5b Are vents tightly screened to prevent insects, rodents and birds from entering?
5b 1) Yes
5b 2) No
5c Are air vents constructed to prevent rain from entering tank?
5c 1) Yes
5c 2) No
6 Access openings
6a Does tank have access openings?
6a 1) Yes
6a 2) No
6b Access opening(s) installed on raised curb
6c Access opening has tight, sanitary door, can be opened without contaminating water
6d Vandalism-proof security locks
6e Manhole type covers are used for access doors
6f If they exist, do manhole covers have holes?
6f 1) Yes, manhole covers have holes
6f 2) No, no holes in manhole covers
7 Is tank site susceptible to runoff or flooding?
7a Yes
7b No
8 Tank overflow/drain lines
8a Discharge to atmosphere, 12-in or more above ground, do not become submerged
8b End of lines screened or have tight-flap-gate
9 Storage capacity
9a Tank can be totally drawn down (emptied) during peak demands
9b Excessive storage capacity
10 Storage controls
10a Water level/pressure controls manually set, difficult or impossible to change
10b Easily changed by operator
10c Levels are managed to minimize water age in tank
11 Tank maintenance
11a Easily isolated with valves for cleaning/maintenance
11b Tank inspected and repaired at least once every 5 years
11c Tank is steel and interior is in need of repair or painting
11d Tank is concrete, has visible cracks or concrete spalling in need of repair
12 Tank cleaning
12a How frequently is tank cleaned?
12a 1) Once every year
12a 2) Every two years
12a 3) Three to Five years
12a 4) Greater than Five years
12b Tank never drained, cleaned and inspected
12c When tank drained and cleaned, strict disinfection procedures used
Part D: Pumping and Storage
II. Storage Facilities
No. 4
Answer Item Item Description
1 Does your system have storage facilities?
1a Yes (Final value should equal 100)
1b No Current Sum of %
2 Storage facility information for All Storage
2 Percent of system's total water storage capacity, % Facilities = 0.0
3 Type of storage facility
3a Ground level, steel, concrete, or fiberglass
3b Elevated, steel or concrete
3c Buried, concrete, steel or fiberglass
3c 1) Tank partially buried
3c 2) Completely buried, soil over top
3c 3) Ground water drainage system in-place and working
3d Hydropneumatic tanks
3d 1) Internal bladder type
3d 2) Tank has no bladder, air contacts water
4 Holes in roof, walls or door; tank cover
4a Is tank uncovered (no roof)?
4a 1) Yes
4a 2) No
4b Does tank have open holes in roof, walls, joints or access doors?
4b 1) Yes
4b 2) No
5 Air vents
5a Does this tank have air vents?
5a 1) Yes
5a 2) No
5b Are vents tightly screened to prevent insects, rodents and birds from entering?
5b 1) Yes
5b 2) No
5c Are air vents constructed to prevent rain from entering tank?
5c 1) Yes
5c 2) No
6 Access openings
6a Does tank have access openings?
6a 1) Yes
6a 2) No
6b Access opening(s) installed on raised curb
6c Access opening has tight, sanitary door, can be opened without contaminating water
6d Vandalism-proof security locks
6e Manhole type covers are used for access doors
6f If they exist, do manhole covers have holes?
6f 1) Yes, manhole covers have holes
6f 2) No, no holes in manhole covers
7 Is tank site susceptible to runoff or flooding?
7a Yes
7b No
8 Tank overflow/drain lines
8a Discharge to atmosphere, 12-in or more above ground, do not become submerged
8b End of lines screened or have tight-flap-gate
9 Storage capacity
9a Tank can be totally drawn down (emptied) during peak demands
9b Excessive storage capacity
10 Storage controls
10a Water level/pressure controls manually set, difficult or impossible to change
10b Easily changed by operator
10c Levels are managed to minimize water age in tank
11 Tank maintenance
11a Easily isolated with valves for cleaning/maintenance
11b Tank inspected and repaired at least once every 5 years
11c Tank is steel and interior is in need of repair or painting
11d Tank is concrete, has visible cracks or concrete spalling in need of repair
12 Tank cleaning
12a How frequently is tank cleaned?
12a 1) Once every year
12a 2) Every two years
12a 3) Three to Five years
12a 4) Greater than Five years
12b Tank never drained, cleaned and inspected
12c When tank drained and cleaned, strict disinfection procedures used
0 No. of Storage Facilities
0 Sum of Percent of Total Storage Capacity
0 Sum of Percent of Total Storage Capacity
100 Maximum Percent that can be Entered for No. 1
100 Maximum Percent that can be Entered for No. 2
100 Maximum Percent that can be Entered for No. 3
100 Maximum Percent that can be Entered for No. 4
II. Storage Facilities
No. 1
Comments –
II. Storage Facilities
No. 2
Comments –
II. Storage Facilities
No. 3
Comments –
II. Storage Facilities
No. 4
Comments –
Part E: Transmission and Distribution
I. Transmission Pipelines I. Transmission Pipelines
No. 1 No. 1
Answer Item Item Description Comments –
1 Does water system have a transmission pipeline?
1a Yes
1b No
2 Type of transmission pipeline (Value can be less than or equal to 100)
2a Raw, untreated water Current Sum of % for All:
2b Finished, treated water Raw Water T ransmission Pipelines = 0.0
2c Total length of pipeline, miles of pipe T reated Water T ransmission Pipelines = 0.0
2d Percent of system's annual water requirements provided by this pipeline, %
3 Materials of construction (Indicate approximate % below)
3a Unlined cast iron pipe
3b Lined cast or ductile iron pipe
3c PVC (Value should equal 100)
3d Polyethylene Current Sum of %
3e Unlined steel for All Pipe T ypes =
3f Lined steel 0
3g Reinforced concrete
3h Prestressed concrete cylinder pipe
3i Asbestos Cement (AC)
4 Pressure and pressure zones
4a Maximum system pressure (psi)
4b Minimum system pressure (psi)
4c Number of pressure zones
4d Can there be a condition where there is no water pressure in this pipeline?
4d 1) Yes
4d 2) No
5 Integrity of pipeline joints
Are pipe joints water tight under pressure?
5a Yes
5b No
5c No information available
6 Maintenance
6a Pipeline appurtenances for this pipeline
6a 1) Line isolation valves
6a 2) Air release/vacuum relief valves
6a 3) Pressure sustaining/pressure reducing/pressure relief valves (any of these)
6a 4) Blow-off lines
6b Who performs maintenance?
6b 1) Water system staff/operators
6b 2) Outside, private contractors
6c What maintenance is performed?
6c 1) Pipeline flushed regularly (at least every 2 years)
6c 2) Line isolation valves exercised at least once per year
6c 3) Air release/vacuum relief valves are inspected at least once per year
6c 4) Pressure sustaining/reducing/relief valves are inspected at least once per year
6c 5) Blow-off lines are inspected at least once per year
7 Repairs
7a Who performs repairs for this pipeline?
7a 1) Water system staff/operators
7a 2) Outside, private contractor
7b Who is responsible for inspection of flushing, disinfection and BacT testing?
7b 1) Water system staff/operators
7b 2) Outside, private contractors
8 Pipeline structures
8a Do concrete manholes or head-breaking structures exist?
8a 1) Yes
8a 2) No
8a 3) If answer to question 8a was YES, how many structures are there?
8b Do structures have unscreened holes or allow rain, insects or rodents to enter?
8b 1) Yes
8b 2) No
9 Service lines
9a Are any service lines to customers connected to pipeline?
9a 1) Yes
9a 2) No
9b If finished water pipeline, is there sufficient CxT for all connected customers?
9b 1) Yes
9b 2) No
9b 3) Do not have any information
9b 4) Does not apply to this pipeline
10 Possible contamination hazards
10a Fire hydrants
10a 1) Are any fire hydrants attached to pipeline?
10a 1)(a) Yes
10a 1)(b) No
10a 2) Are backflow prevention valves required/provided for temporary fire hydrant connections?
10a 2)(a) Yes
10a 2)(b) No
10b Air release/vacuum relief valves
10b 1) Air release/vacuum relief valve located below grade and subject to flooding
10b 2) Inlet/outlet (for air release or vacuum relief) above ground and above any potential flooding
10b 3) End of inlet/outlet pipe is turned-down and has tight, insect screen installed
10b 4) Inlet/outlet pipe has drain holes
10c Pipeline blow-offs
10c 1) Blow-off lines discharge to atmosphere, 12 inches above any water surface
10c 2) End of blow-off lines equipped have tight screen, valve or capped
10c 3) Blow-off line has drain holes that are buried in gravel or other drain material
10d Sewers
10d 1) Sewers exist in same streets or right-of-ways, or w/in 50 feet of pipeline
10d 2) Ground water table can exist at an elevation above the water and sewer lines
10d 3) Septic tanks and/or drainfields within 100 feet of pipeline
10e Is the water in this pipeline pumped or controlled by a downstream booster pump?
10e 1) Yes
10e 2) No
10f Are hydraulic surges or water hammer created when pumps turn off or on?
10f 1) Yes
10f 2) No
11 System records
11a Maps are available that show the following features of pipeline:
11a 1) Location of pipes
11a 2) Location of valves
11a 3) Pipe size
11a 4) Pipe materials of construction
11b Only limited maps of transmission system are available
11c No maps or drawings are available for transmission system
Part E: Transmission and Distribution
I. Transmission Pipelines I. Transmission Pipelines
No. 2 No. 2
Answer Item Item Description Comments –
1 Does water system have a transmission pipeline?
1a Yes
1b No
2 Type of transmission pipeline (Value can be less than or equal to 100)
2a Raw, untreated water Current Sum of % for All:
2b Finished, treated water Raw Water T ransmission Pipelines = 0.0
2c Total length of pipeline, miles of pipe T reated Water T ransmission Pipelines = 0.0
2d Percent of system's annual water requirements provided by this pipeline, %
3 Materials of construction (Indicate approximate % below)
3a Unlined cast iron pipe
3b Lined cast or ductile iron pipe
3c PVC (Value should equal 100)
3d Polyethylene Current Sum of %
3e Unlined steel for All Pipe T ypes =
3f Lined steel 0
3g Reinforced concrete
3h Prestressed concrete cylinder pipe
3i Asbestos Cement (AC)
4 Pressure and pressure zones
4a Maximum system pressure (psi)
4b Minimum system pressure (psi)
4c Number of pressure zones
4d Can there be a condition where there is no water pressure in this pipeline?
4d 1) Yes
4d 2) No
5 Integrity of pipeline joints
Are pipe joints water tight under pressure?
5a Yes
5b No
5c No information available
6 Maintenance
6a Pipeline appurtenances for this pipeline
6a 1) Line isolation valves
6a 2) Air release/vacuum relief valves
6a 3) Pressure sustaining/pressure reducing/pressure relief valves (any of these)
6a 4) Blow-off lines
6b Who performs maintenance?
6b 1) Water system staff/operators
6b 2) Outside, private contractors
6c What maintenance is performed?
6c 1) Pipeline flushed regularly (at least every 2 years)
6c 2) Line isolation valves exercised at least once per year
6c 3) Air release/vacuum relief valves are inspected at least once per year
6c 4) Pressure sustaining/reducing/relief valves are inspected at least once per year
6c 5) Blow-off lines are inspected at least once per year
7 Repairs
7a Who performs repairs for this pipeline?
7a 1) Water system staff/operators
7a 2) Outside, private contractor
7b Who is responsible for inspection of flushing, disinfection and BacT testing?
7b 1) Water system staff/operators
7b 2) Outside, private contractors
8 Pipeline structures
8a Do concrete manholes or head-breaking structures exist?
8a 1) Yes
8a 2) No
8a 3) If answer to question 8a was YES, how many structures are there?
8b Do structures have unscreened holes or allow rain, insects or rodents to enter?
8b 1) Yes
8b 2) No
9 Service lines
9a Are any service lines to customers connected to pipeline?
9a 1) Yes
9a 2) No
9b If finished water pipeline, is there sufficient CxT for all connected customers?
9b 1) Yes
9b 2) No
9b 3) Do not have any information
9b 4) Does not apply to this pipeline
10 Possible contamination hazards
10a Fire hydrants
10a 1) Are any fire hydrants attached to pipeline?
10a 1)(a) Yes
10a 1)(b) No
10a 2) Are backflow prevention valves required/provided for temporary fire hydrant connections?
10a 2)(a) Yes
10a 2)(b) No
10b Air release/vacuum relief valves
10b 1) Air release/vacuum relief valve located below grade and subject to flooding
10b 2) Inlet/outlet (for air release or vacuum relief) above ground and above any potential flooding
10b 3) End of inlet/outlet pipe is turned-down and has tight, insect screen installed
10b 4) Inlet/outlet pipe has drain holes
10c Pipeline blow-offs
10c 1) Blow-off lines discharge to atmosphere, 12 inches above any water surface
10c 2) End of blow-off lines equipped have tight screen, valve or capped
10c 3) Blow-off line has drain holes that are buried in gravel or other drain material
10d Sewers
10d 1) Sewers exist in same streets or right-of-ways, or w/in 50 feet of pipeline
10d 2) Ground water table can exist at an elevation above the water and sewer lines
10d 3) Septic tanks and/or drainfields within 100 feet of pipeline
10e Is the water in this pipeline pumped or controlled by a downstream booster pump?
10e 1) Yes
10e 2) No
10f Are hydraulic surges or water hammer created when pumps turn off or on?
10f 1) Yes
10f 2) No
11 System records
11a Maps are available that show the following features of pipeline:
11a 1) Location of pipes
11a 2) Location of valves
11a 3) Pipe size
11a 4) Pipe materials of construction
11b Only limited maps of transmission system are available
11c No maps or drawings are available for transmission system
Part E: Transmission and Distribution
I. Transmission Pipelines I. Transmission Pipelines
No. 3 No. 3
Answer Item Item Description Comments –
1 Does water system have a transmission pipeline?
1a Yes
1b No
2 Type of transmission pipeline (Value can be less than or equal to 100)
2a Raw, untreated water Current Sum of % for All:
2b Finished, treated water Raw Water T ransmission Pipelines = 0.0
2c Total length of pipeline, miles of pipe T reated Water T ransmission Pipelines = 0.0
2d Percent of system's annual water requirements provided by this pipeline, %
3 Materials of construction (Indicate approximate % below)
3a Unlined cast iron pipe
3b Lined cast or ductile iron pipe
3c PVC (Value should equal 100)
3d Polyethylene Current Sum of %
3e Unlined steel for All Pipe T ypes =
3f Lined steel 0
3g Reinforced concrete
3h Prestressed concrete cylinder pipe
3i Asbestos Cement (AC)
4 Pressure and pressure zones
4a Maximum system pressure (psi)
4b Minimum system pressure (psi)
4c Number of pressure zones
4d Can there be a condition where there is no water pressure in this pipeline?
4d 1) Yes
4d 2) No
5 Integrity of pipeline joints
Are pipe joints water tight under pressure?
5a Yes
5b No
5c No information available
6 Maintenance
6a Pipeline appurtenances for this pipeline
6a 1) Line isolation valves
6a 2) Air release/vacuum relief valves
6a 3) Pressure sustaining/pressure reducing/pressure relief valves (any of these)
6a 4) Blow-off lines
6b Who performs maintenance?
6b 1) Water system staff/operators
6b 2) Outside, private contractors
6c What maintenance is performed?
6c 1) Pipeline flushed regularly (at least every 2 years)
6c 2) Line isolation valves exercised at least once per year
6c 3) Air release/vacuum relief valves are inspected at least once per year
6c 4) Pressure sustaining/reducing/relief valves are inspected at least once per year
6c 5) Blow-off lines are inspected at least once per year
7 Repairs
7a Who performs repairs for this pipeline?
7a 1) Water system staff/operators
7a 2) Outside, private contractor
7b Who is responsible for inspection of flushing, disinfection and BacT testing?
7b 1) Water system staff/operators
7b 2) Outside, private contractors
8 Pipeline structures
8a Do concrete manholes or head-breaking structures exist?
8a 1) Yes
8a 2) No
8a 3) If answer to question 8a was YES, how many structures are there?
8b Do structures have unscreened holes or allow rain, insects or rodents to enter?
8b 1) Yes
8b 2) No
9 Service lines
9a Are any service lines to customers connected to pipeline?
9a 1) Yes
9a 2) No
9b If finished water pipeline, is there sufficient CxT for all connected customers?
9b 1) Yes
9b 2) No
9b 3) Do not have any information
9b 4) Does not apply to this pipeline
10 Possible contamination hazards
10a Fire hydrants
10a 1) Are any fire hydrants attached to pipeline?
10a 1)(a) Yes
10a 1)(b) No
10a 2) Are backflow prevention valves required/provided for temporary fire hydrant connections?
10a 2)(a) Yes
10a 2)(b) No
10b Air release/vacuum relief valves
10b 1) Air release/vacuum relief valve located below grade and subject to flooding
10b 2) Inlet/outlet (for air release or vacuum relief) above ground and above any potential flooding
10b 3) End of inlet/outlet pipe is turned-down and has tight, insect screen installed
10b 4) Inlet/outlet pipe has drain holes
10c Pipeline blow-offs
10c 1) Blow-off lines discharge to atmosphere, 12 inches above any water surface
10c 2) End of blow-off lines equipped have tight screen, valve or capped
10c 3) Blow-off line has drain holes that are buried in gravel or other drain material
10d Sewers
10d 1) Sewers exist in same streets or right-of-ways, or w/in 50 feet of pipeline
10d 2) Ground water table can exist at an elevation above the water and sewer lines
10d 3) Septic tanks and/or drainfields within 100 feet of pipeline
10e Is the water in this pipeline pumped or controlled by a downstream booster pump?
10e 1) Yes
10e 2) No
10f Are hydraulic surges or water hammer created when pumps turn off or on?
10f 1) Yes
10f 2) No
11 System records
11a Maps are available that show the following features of pipeline:
11a 1) Location of pipes
11a 2) Location of valves
11a 3) Pipe size
11a 4) Pipe materials of construction
11b Only limited maps of transmission system are available
11c No maps or drawings are available for transmission system
Part E: Transmission and Distribution
I. Transmission Pipelines I. Transmission Pipelines
No. 4 No. 4
Answer Item Item Description Comments –
1 Does water system have a transmission pipeline?
1a Yes
1b No
2 Type of transmission pipeline (Value can be less than or equal to 100)
2a Raw, untreated water Current Sum of % for All:
2b Finished, treated water Raw Water T ransmission Pipelines = 0.0
2c Total length of pipeline, miles of pipe T reated Water T ransmission Pipelines = 0.0
2d Percent of system's annual water requirements provided by this pipeline, %
3 Materials of construction (Indicate approximate % below)
3a Unlined cast iron pipe
3b Lined cast or ductile iron pipe
3c PVC (Value should equal 100)
3d Polyethylene Current Sum of %
3e Unlined steel for All Pipe T ypes =
3f Lined steel 0
3g Reinforced concrete
3h Prestressed concrete cylinder pipe
3i Asbestos Cement (AC)
4 Pressure and pressure zones
4a Maximum system pressure (psi)
4b Minimum system pressure (psi)
4c Number of pressure zones
4d Can there be a condition where there is no water pressure in this pipeline?
4d 1) Yes
4d 2) No
5 Integrity of pipeline joints
Are pipe joints water tight under pressure?
5a Yes
5b No
5c No information available
6 Maintenance
6a Pipeline appurtenances for this pipeline
6a 1) Line isolation valves
6a 2) Air release/vacuum relief valves
6a 3) Pressure sustaining/pressure reducing/pressure relief valves (any of these)
6a 4) Blow-off lines
6b Who performs maintenance?
6b 1) Water system staff/operators
6b 2) Outside, private contractors
6c What maintenance is performed?
6c 1) Pipeline flushed regularly (at least every 2 years)
6c 2) Line isolation valves exercised at least once per year
6c 3) Air release/vacuum relief valves are inspected at least once per year
6c 4) Pressure sustaining/reducing/relief valves are inspected at least once per year
6c 5) Blow-off lines are inspected at least once per year
7 Repairs
7a Who performs repairs for this pipeline?
7a 1) Water system staff/operators
8/7/2012
7a 2) Outside, private contractor
7b Who is responsible for inspection of flushing, disinfection and BacT testing?
7b 1) Water system staff/operators
7b 2) Outside, private contractors
8 Pipeline structures
8a Do concrete manholes or head-breaking structures exist?
8a 1) Yes
8a 2) No
8a 3) If answer to question 8a was YES, how many structures are there?
8b Do structures have unscreened holes or allow rain, insects or rodents to enter?
8b 1) Yes
8b 2) No
9 Service lines
9a Are any service lines to customers connected to pipeline?
9a 1) Yes
9a 2) No
9b If finished water pipeline, is there sufficient CxT for all connected customers?
9b 1) Yes
9b 2) No
9b 3) Do not have any information
9b 4) Does not apply to this pipeline
10 Possible contamination hazards
10a Fire hydrants
10a 1) Are any fire hydrants attached to pipeline?
10a 1)(a) Yes
10a 1)(b) No
10a 2) Are backflow prevention valves required/provided for temporary fire hydrant connections?
10a 2)(a) Yes
10a 2)(b) No
10b Air release/vacuum relief valves
10b 1) Air release/vacuum relief valve located below grade and subject to flooding
10b 2) Inlet/outlet (for air release or vacuum relief) above ground and above any potential flooding
10b 3) End of inlet/outlet pipe is turned-down and has tight, insect screen installed
10b 4) Inlet/outlet pipe has drain holes
10c Pipeline blow-offs
10c 1) Blow-off lines discharge to atmosphere, 12 inches above any water surface
10c 2) End of blow-off lines equipped have tight screen, valve or capped
10c 3) Blow-off line has drain holes that are buried in gravel or other drain material
10d Sewers
10d 1) Sewers exist in same streets or right-of-ways, or w/in 50 feet of pipeline
10d 2) Ground water table can exist at an elevation above the water and sewer lines
10d 3) Septic tanks and/or drainfields within 100 feet of pipeline
10e Is the water in this pipeline pumped or controlled by a downstream booster pump?
10e 1) Yes
10e 2) No
10f Are hydraulic surges or water hammer created when pumps turn off or on?
10f 1) Yes
10f 2) No
11 System records
11a Maps are available that show the following features of pipeline:
11a 1) Location of pipes
11a 2) Location of valves
11a 3) Pipe size
11a 4) Pipe materials of construction
11b Only limited maps of transmission system are available
11c No maps or drawings are available for transmission system
0 No. of Transmission Pipelines
0 Sum of Percent of Total Supply for Transmission Pipelines
0 Sum of Percent of Total Supply for Transmission Pipelines
100 Maximum Percent that can be Entered for No. 1
100 Maximum Percent that can be Entered for No. 2
100 Maximum Percent that can be Entered for No. 3
100 Maximum Percent that can be Entered for No. 4
0 No. of Raw Water Transmission Pipelines
0 Sum of Percent of Total Supply for RAW Transmission Pipelines
0 Sum of Percent of Total Supply for RAW Transmission Pipelines
0 Percent entered for No. 1 if Raw Pipeline
0 Percent entered for No. 2 if Raw Pipeline
0 Percent entered for No. 3 if Raw Pipeline
0 Percent entered for No. 4 if Raw Pipeline
100 Maximum Percent that can be Entered for No. 1
100 Maximum Percent that can be Entered for No. 2
100 Maximum Percent that can be Entered for No. 3
100 Maximum Percent that can be Entered for No. 4
0 No. of Finished Water Transmission Pipelines
0 Sum of Percent of Total Supply for Finished Transmission Pipelines
0 Sum of Percent of Total Supply for Finished Transmission Pipelines
0 Percent entered for No. 1 if Finished Pipeline
0 Percent entered for No. 2 if Finished Pipeline
0 Percent entered for No. 3 if Finished Pipeline
0 Percent entered for No. 4 if Finished Pipeline
100 Maximum Percent that can be Entered for No. 1
100 Maximum Percent that can be Entered for No. 2
100 Maximum Percent that can be Entered for No. 3
100 Maximum Percent that can be Entered for No. 4
8/7/2012
Part E: Transmission and Distribution
II. Distribution System II. Distribution System
Answer Item Item Description Comments –
1 Does your system have a distribution system?
1a Yes
1b No
2 Materials of construction (Indicate approximate % below)
2a Unlined cast iron pipe
2b Lined cast or ductile iron pipe
2c PVC (Value should equal 100)
2d Polyethylene Current Sum of %
2e Unlined steel for All Pipe Types =
2f Lined steel 0
2g Galvanized steel
2h Asbestos cement
3 Pressure and pressure zones
3a Maximum system pressure (psi)
3b Minimum system pressure (psi)
3c Number of pressure zones
4 Maintenance
4a Pipeline appurtenances in distribution system
4a 1) Line isolation valves
4a 2) Air release/vacuum relief valves
4a 3) Pressure sustaining/reducing/relief valves
4a 4) Blow-off lines
4b Who performs maintenance?
4b 1) Water system staff/operators
4b 2) Outside, private contractors
4c What maintenance is performed?
4c 1) System flushed regularly (at least every 2 years)
4c 2) Line isolation valves exercised at least once per year
4c 3) Air release/vacuum relief valves are inspected at least once per year
4c 4) Pressure sustaining/reducing/relief valves are inspected at least once per year
4c 5) Blow-off lines are inspected at least once per year
5 Repairs
5a Who performs repairs?
5a 1) Water system staff/operator
5a 2) Outside, private contractor
5b Who is responsible for flushing, disinfection and BacT testing of repairs?
5b 1) Water system staff/operators
5b 2) Outside, private contractors
6 Service lines and meters
6a Is water system metered?
6a 1) Yes
6a 2) No
6b Who installs service lines and meters?
6b 1) Water system staff/operators
6b 2) Outside, private contractors
6c Who is responsible for flushing, disinfection and BacT testing?
6c 1) Water system staff/operators
6c 2) Outside, private contractors
7 New construction of distribution pipelines and related facilities
7a Who performs new construction?
7a 1) All new construction by water system staff/operators
7a 2) Some by water system staff/operators, some by outside, private contractors
7a 3) All new construction by outside, private contractors
7b Who is responsible for flushing, disinfection and BacT testing new construction?
7b 1) Water system staff/operators
7b 2) Outside, private contractors
8 Possible contamination hazards
8a Fire hydrants
8a 1) Are any fire hydrants attached to pipeline?
8a 1)(a) Yes
8a 1)(b) No
8a 2) Are backflow prevention valves required/provided for temporary fire hydrant connections?
8a 2)(a) Yes
8a 2)(b) No
8b Air release/vacuum relief valves
8b 1) Air release/vacuum relief valve located below grade and subject to flooding
8b 2) Inlet/outlet (for air release or vacuum relief) above ground and above any potential flooding
8b 3) End of inlet/outlet pipe is turned-down and has tight, insect screen installed
8b 4) Inlet/outlet pipe has drain holes
8c Pipeline blow-offs
8c 1) Blow-off lines discharge to atmosphere, 12 inches above any water surface
8c 2) End of blow-off lines equipped have tight screen, valve or capped
8c 3) Blow-off line has drain holes that are buried in gravel or other drain material
8d Sewers
8d 1) Sewers exist in same streets or right-of-ways, or w/in 50 feet of pipeline
8d 2) Ground water table can exist at an elevation above the water and sewer lines
8d 3) Septic tanks and/or drainfields within 100 feet of pipeline
8e Does hydraulic surges or water hammer exist within distribution system?
8e 1) Yes
8e 2) No
8f Is there significant water loss due to leakage?
8f 1) Yes
8f 2) No
8f 3) No information is available
9 Dead-ends and low-flow areas
9a Approximately how many dead-end pipelines does the system have?
9b Approximately how many areas exist where the distribution system is looped, but the area
has low flows due to low demands or other reasons?
9c Are total coliform samples taken at or near either a dead-end or a low-flow area?
9c 1) Yes
9c 2) No
9d If answer to 9c was yes, have samples been positive for coliforms in the last 3 years?
9d 1) Yes
9d 2) No
9e Have disinfectant concentrations dropped below 0.2 mg/L in dead-end/low-flow area?
9e 1) Yes
9e 2) No
9e 3) Do not measure disinfectant residuals in these areas
10 Cross-connections - backflow prevention
10a Does water system have an approved cross-connection control program?
10a 1) Yes
10a 2) No
10b Do water system personnel inspect and enforce cross-connection control program?
10b 1) Yes
10b 2) No
10c Does water system or government unit have policies requiring backflow prevention?
10c 1) Yes
10c 2) No
10d Are lawn irrigation systems checked for proper backflow prevention devices?
10d 1) Yes
10d 2) No
10e Is potable water used at sewage pump stations or sewage treatment facilities?
10e 1) Yes
10e 2) No
10f If the answer to 10e was yes, are backflow prevention devices installed on service lines?
10f 1) Yes
10f 2) No
11 System records
11a Maps are available that show the following features of pipeline:
11a 1) Location of pipes
11a 2) Location of valves
11a 3) Pipe size
11a 4) Pipe materials of construction
11a 5) Fire hydrants
11b Only limited maps of distribution system are available
11c No maps or drawings are available for distribution system
12 Residual disinfection
12a Type of residual disinfectant
12 a 1) Free chlorine
12a 2) Chloramines
12a 3) Chlorine dioxide
12a 4) Water does not require addition of a disinfectant
12b Is residual disinfectant concentration in system measured on regular basis?
12b 1) Yes
12b 2) No
12c Do residual disinfectant concentrations drop below 0.2 mg/L in any part of system?
12c 1) Yes
12c 2) No
12c 3) Do not have this information
12d If water not disinfected, are facilities, equipment and chemicals available for addition of disinfectant?
12d 1) Yes
12d 2) No
8/7/2012
Part F: Water Quality Monitoring
Part F: Water Quality Monitoring
Answer Item Item Description Comments –
1 Source water monitoring Source water monitoring (per day)
1a Does your water system purchase treated water from another entity? Surface_Source Purchase_Treated_Source
1a 1) Yes 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 2 3 4 5 6 7 8 9 10 11 12 13 14
1a 2) No Population Total E. coli Disinf. Corrsn. Population Total E. coli Disinf. Corrsn.
1b Is source water quality monitored? (water before any form of treatment) Served Turbidity Coliform HPC fecal colif. Giardia Crypto pH Temp TOC NO2/NO3 Residual Chemical Alkalinity Served Turbidity Coliform HPC fecal colif. Giardia Crypto pH Temp TOC NO2/NO3 Residual Chemical Alkalinity
1b 1) Yes 1 6 0.14286 0.14286 0.14286 0.03288 0.03288 1 1 0.03288 0.03288 0 0 0.03288 1 0 0 0 0 0 0 0 0 0 0 0 0 0
1b 2) No 25 6 0.14286 0.14286 0.14286 0.03288 0.03288 1 1 0.03288 0.03288 0 0 0.03288 25 0 0 0 0 0 0 0 0 0 0 0 0 0
1c If answer to 1b above was YES, what is frequency of monitoring source water? 26 6 0.14286 0.14286 0.14286 0.03288 0.03288 1 1 0.03288 0.03288 0 0 0.03288 26 0 0 0 0 0 0 0 0 0 0 0 0 0
1c 1) Turbidity 500 6 0.14286 0.14286 0.14286 0.03288 0.03288 1 1 0.03288 0.03288 0 0 0.03288 500 0 0 0 0 0 0 0 0 0 0 0 0 0
a) Number of samples 501 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 0 0 0.03288 501 0 0 0 0 0 0 0 0 0 0 0 0 0
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 1001 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 0 0 0.03288 1001 0 0 0 0 0 0 0 0 0 0 0 0 0
1c 2) Total Coliform 1000 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 0 0 0.03288 1000 0 0 0 0 0 0 0 0 0 0 0 0 0
a) Number of samples 2500 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 0 0 0.03288 2500 0 0 0 0 0 0 0 0 0 0 0 0 0
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 2501 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 0 0 0.03288 2501 0 0 0 0 0 0 0 0 0 0 0 0 0
1c 3) HPC (heterotrophic plate count) 3300 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 0 0 0.03288 3300 0 0 0 0 0 0 0 0 0 0 0 0 0
a) Number of samples 3301 6 0.42857 0.42857 0.42857 0.03288 0.03288 2 2 0.03288 0.03288 0 0 0.03288 3301 0 0 0 0 0 0 0 0 0 0 0 0 0
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 4100 6 0.42857 0.42857 0.42857 0.03288 0.03288 2 2 0.03288 0.03288 0 0 0.03288 4100 0 0 0 0 0 0 0 0 0 0 0 0 0
1c 4) E. coli or fecal coliform 4101 6 0.42857 0.42857 0.42857 0.03288 0.03288 4 4 0.03288 0.03288 0 0 0.03288 4101 0 0 0 0 0 0 0 0 0 0 0 0 0
a) Number of samples 10000 6 0.42857 0.42857 0.42857 0.03288 0.03288 4 4 0.03288 0.03288 0 0 0.03288 10000 0 0 0 0 0 0 0 0 0 0 0 0 0
b) Time Period, insert a number (day=1, week=2, month=3 or year=4)
1c 5) Giardia Ground_Source
a) Number of samples 1 2 3 4 5 6 7 8 9 10 11 12 13 14
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) Population Total E. coli Disinf. Corrsn.
1c 6) Cryptosporidium Served Turbidity Coliform HPC fecal colif. Giardia Crypto pH Temp TOC NO2/NO3 Residual Chemical Alkalinity
a) Number of samples 1 6 0.14286 0.14286 0.14286 0 0 1 1 0.03288 0.03288 0 0 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 25 6 0.14286 0.14286 0.14286 0 0 1 1 0.03288 0.03288 0 0 0.03288
1c 7) pH 26 6 0.14286 0.14286 0.14286 0 0 1 1 0.03288 0.03288 0 0 0.03288
a) Number of samples 500 6 0.14286 0.14286 0.14286 0 0 1 1 0.03288 0.03288 0 0 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 501 6 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0 0 0.03288
1c 8) Temperature 1001 6 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0 0 0.03288
a) Number of samples 1000 6 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0 0 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 2500 6 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0 0 0.03288
1c 9) Total Organic Carbon (TOC) 2501 6 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0 0 0.03288
a) Number of samples 3300 6 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0 0 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 3301 6 0.42857 0.42857 0.42857 0 0 2 2 0.03288 0.03288 0 0 0.03288
1c 10) Nitrite and/or Nitrate 4100 6 0.42857 0.42857 0.42857 0 0 2 2 0.03288 0.03288 0 0 0.03288
a) Number of samples 4101 6 0.42857 0.42857 0.42857 0 0 4 4 0.03288 0.03288 0 0 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 10000 6 0.42857 0.42857 0.42857 0 0 4 4 0.03288 0.03288 0 0 0.03288
1c 11) Alkalinity
a) Number of samples
b) Time Period, insert a number (day=1, week=2, month=3 or year=4)
2 Treated water monitoring (prior to entering the distribution system) Treated water monitoring (prior to entering the distribution system)
2a Is treated water quality monitored? Surface_Treated
2a 1) Yes 1 2 3 4 5 6 7 8 9 10 11 12 13 14
2a 2) No Population Total E. coli Disinf. Corrsn.
2b If answer to 2a above was YES, what is frequency of monitoring treated water? Served Turbidity Coliform HPC fecal colif. Giardia Crypto pH Temp TOC NO2/NO3 Residual Chemical Alkalinity
2b 1) Turbidity 1 6 0.14286 0.14286 0.14286 0.03288 0.03288 1 1 0.03288 0.03288 1 0.14286 0.03288
a) Number of samples 25 6 0.14286 0.14286 0.14286 0.03288 0.03288 1 1 0.03288 0.03288 1 0.14286 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 26 6 0.14286 0.14286 0.14286 0.03288 0.03288 1 1 0.03288 0.03288 1 0.14286 0.03288
2b 2) Total Coliform 500 6 0.14286 0.14286 0.14286 0.03288 0.03288 1 1 0.03288 0.03288 1 0.14286 0.03288
a) Number of samples 501 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 2 0.14286 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 1001 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 2 0.14286 0.03288
2b 3) HPC (heterotrophic plate count) 1000 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 3 0.14286 0.03288
a) Number of samples 2500 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 3 0.14286 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 2501 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 4 0.14286 0.03288
2b 4) E. coli or fecal coliform 3300 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 4 0.14286 0.03288
a) Number of samples 3301 96 0.42857 0.42857 0.42857 0.03288 0.03288 2 2 0.06575 0.06575 96 0.28571 0.14286
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 4100 96 0.42857 0.42857 0.42857 0.03288 0.03288 2 2 0.06575 0.06575 96 0.28571 0.14286
2b 5) Giardia 4101 96 0.42857 0.42857 0.42857 0.03288 0.03288 4 4 0.06575 0.06575 96 0.28571 0.14286
a) Number of samples 10000 96 0.42857 0.42857 0.42857 0.03288 0.03288 4 4 0.06575 0.06575 96 0.28571 0.14286
b) Time Period, insert a number (day=1, week=2, month=3 or year=4)
2b 6) Cryptosporidium Ground_Treated
a) Number of samples 1 2 3 4 5 6 7 8 9 10 11 12 13 14
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) Population Total E. coli Disinf. Corrsn.
2b 7) pH Served Turbidity Coliform HPC fecal colif. Giardia Crypto pH Temp TOC NO2/NO3 Residual Chemical Alkalinity
a) Number of samples 1 0.14286 0.14286 0.14286 0.14286 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 25 0.14286 0.14286 0.14286 0.14286 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
2b 8) Temperature 26 0.14286 0.14286 0.14286 0.14286 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
a) Number of samples 500 0.14286 0.14286 0.14286 0.14286 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 501 0.28571 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
2b 9) Total Organic Carbon (TOC) 1001 0.28571 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
a) Number of samples 1000 0.28571 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 2500 0.28571 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
2b 10) Nitrite and/or Nitrate 2501 0.28571 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
a) Number of samples 3300 0.28571 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 3301 0.42857 0.42857 0.42857 0.42857 0 0 2 2 0.06575 0.06575 0.14286 0.14286 0.03288
2b 11) Chlorine or other disinfectant concentration 4100 0.42857 0.42857 0.42857 0.42857 0 0 2 2 0.06575 0.06575 0.14286 0.14286 0.03288
a) Number of samples 4101 0.42857 0.42857 0.42857 0.42857 0 0 4 4 0.06575 0.06575 0.14286 0.14286 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 10000 0.42857 0.42857 0.42857 0.42857 0 0 4 4 0.06575 0.06575 0.14286 0.14286 0.03288
2b 12) Concentration of corrosion control chemical
a) Number of samples
b) Time Period, insert a number (day=1, week=2, month=3 or year=4)
2b 13) Alkalinity
a) Number of samples
b) Time Period, insert a number (day=1, week=2, month=3 or year=4)
2c Does water come from a surface water source?
2c 1) Yes
2c 2) No
2d Has treated water turbidity exceeded standards?
2d 1) Turbidity measurements are not required for this system
2d 2) Yes
2d 3) No
2e Treated water disinfectant concentration
2e 1) Disinfection not required
2e 2) Have disinfectant concentrations been too low?
2e 2) a) Yes
2e 2) b) No
3 Distributed water sampling Distributed water sampling
3a Sampling plan Surface_Distributed
3a 1) A sampling site plan exists and is followed 1 2 3 4 5 6 7 8 9 10 11 12 13 14
3a 2) Additional points not on sample plan are routinely sampled Population Total E. coli Disinf. Corrsn.
3b Sampling Frequency in Distribution System Served Turbidity Coliform HPC fecal colif. Giardia Crypto pH Temp TOC NO2/NO3 Residual Chemical Alkalinity
3b 1) Chlorine residual, free or total 1 6 0.14286 0.14286 0.14286 0.03288 0.03288 1 1 0.03288 0.03288 1 0.14286 0.03288
a) Number of samples 25 6 0.14286 0.14286 0.14286 0.03288 0.03288 1 1 0.03288 0.03288 1 0.14286 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 26 6 0.14286 0.14286 0.14286 0.03288 0.03288 1 1 0.03288 0.03288 1 0.14286 0.03288
3b 2) Total Coliform 500 6 0.14286 0.14286 0.14286 0.03288 0.03288 1 1 0.03288 0.03288 1 0.14286 0.03288
a) Number of samples 501 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 2 0.14286 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 1001 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 2 0.14286 0.03288
3b 3) HPC (heterotrophic plate count) 1000 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 3 0.14286 0.03288
a) Number of samples 2500 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 3 0.14286 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 2501 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 4 0.14286 0.03288
3b 4) E. coli or fecal coliform 3300 6 0.28571 0.28571 0.28571 0.03288 0.03288 1 1 0.03288 0.03288 4 0.14286 0.03288
a) Number of samples 3301 96 0.42857 0.42857 0.42857 0.03288 0.03288 2 2 0.06575 0.06575 96 0.28571 0.14286
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 4100 96 0.42857 0.42857 0.42857 0.03288 0.03288 2 2 0.06575 0.06575 96 0.28571 0.14286
3b 5) pH 4101 96 0.42857 0.42857 0.42857 0.03288 0.03288 4 4 0.06575 0.06575 96 0.28571 0.14286
a) Number of samples 10000 96 0.42857 0.42857 0.42857 0.03288 0.03288 4 4 0.06575 0.06575 96 0.28571 0.14286
b) Time Period, insert a number (day=1, week=2, month=3 or year=4)
3b 6) Temperature Ground_Distributed
a) Number of samples 1 2 3 4 5 6 7 8 9 10 11 12 13 14
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) Population Total E. coli Disinf. Corrsn.
3b 7) Corrosion control chemical concentration Served Turbidity Coliform HPC fecal colif. Giardia Crypto pH Temp TOC NO2/NO3 Residual Chemical Alkalinity
a) Number of samples 1 0.14286 0.14286 0.14286 0.14286 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 25 0.14286 0.14286 0.14286 0.14286 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
3b 8) Nitrite or Nitrate 26 0.14286 0.14286 0.14286 0.14286 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
a) Number of samples 500 0.14286 0.14286 0.14286 0.14286 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
b) Time Period, insert a number (day=1, week=2, month=3 or year=4) 501 0.28571 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
3c Treated water residual disinfectant concentration 1001 0.28571 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
3c 1) Disinfection not required 1000 0.28571 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
3c 2) Have disinfectant concentrations been too low? 2500 0.28571 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
3c 2) a) Yes 2501 0.28571 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
3c 2) b) No 3300 0.28571 0.28571 0.28571 0.28571 0 0 1 1 0.03288 0.03288 0.14286 0.14286 0.03288
3d Distribution sample results within the last 12 months 3301 0.42857 0.42857 0.42857 0.42857 0 0 2 2 0.06575 0.06575 0.14286 0.14286 0.03288
3d 1) Positive total coliform samples 4100 0.42857 0.42857 0.42857 0.42857 0 0 2 2 0.06575 0.06575 0.14286 0.14286 0.03288
3d 2) Positive total coliform results in a series of repeat samples 4101 0.42857 0.42857 0.42857 0.42857 0 0 4 4 0.06575 0.06575 0.14286 0.14286 0.03288
3d 3) High HPC count (greater than 500 colony forming units per milliliter) 10000 0.42857 0.42857 0.42857 0.42857 0 0 4 4 0.06575 0.06575 0.14286 0.14286 0.03288
3d 4) Positive E. coli or fecal coliform sample(s)
3d 5) High nitrate concentrations (>10 milligrams per liter as nitrogen)
3d 6) High nitrite concentrations (>1 milligram per liter as nitrogen)
3d 7) Have had to issue a boil order notice to the customers
3d 8) Non-detectable disinfectant residual concentrations in distribution system
3e Actions taken when a positive coliform sample occurs
3e 1) Repeat sampling as required by regulations
3e 2) Immediate investigation of possible sources of contamination
3e 3) Distribution system flushing
3e 4) Increase disinfectant dose
4 Microbiological sample handling and analysis (please mark those that apply)
4a Does person who samples for regulatory compliance have appropriate training?
4a 1) Yes
4a 2) No
4b Samples are shipped to an outside lab
4c Samples are immediately transported to lab by water system personnel
4d Samples are stored in a refrigerator if there is a delay in getting the
sample to the lab the day the sample is taken
4e Samples shipped to outside lab are packed in coolers with "blue-ice"
4f Samples are processed by water system staff/operators
4g Water system staff/operators are certified for microbiological sampling and analysis
4h Water system has proper facilities for performing microbiological analyses
8/7/2012
Summary of Scores
Part B: Water Source
Sum of Percent of Annual Supply for All Sources = 0 (Value Should Equal 100)
Part B: Water Source –
I. Surface Water - Stream or River
No. 1 No. 2 No. 3 No. 4 Total Weighted No. 1 No. 2 No. 3 No. 4 Total Weighted
B.I. Summary by Stream/River Source
Item Score – Item Score –
No. Component Score Score Score Score Part B.I. No. Component Score Score Score Score Part B.I.
2–Source Water Assessment
2 Source Water Assessment 0.000 0.000 0.000 0.000 0.000 SW Intake-9 9 9–Surface water intake structures 0.000 0.000 0.000 0.000 0.000
3–Source Water Protection Program 3 Source Water Protection Program 0.000 0.000 0.000 0.000 0.000 Strm Wtr-8 8 8–Upstream stormwater discharges/runoff 0.000 0.000 0.000 0.000 0.000
4 Management of land use and activities 0.000 0.000 0.000 0.000 0.000 WW Dschrg-7 7 7–Upstream wastewater discharges 0.000 0.000 0.000 0.000 0.000
4–Management of land use and activities 5 Native and domestic animals in watershed 0.000 0.000 0.000 0.000 0.000 Human access-6 6 6–Human access / activities within watershed 0.000 0.000 0.000 0.000 0.000
6 Human access / activities within watershed 0.000 0.000 0.000 0.000 0.000 Animals-5 5 5–Native and domestic animals in watershed 0.000 0.000 0.000 0.000 0.000
5–Native and domestic animals in watershed 7 Upstream wastewater discharges 0.000 0.000 0.000 0.000 0.000 Lnd Use Mngmnt-4 4 4–Management of land use and activities 0.000 0.000 0.000 0.000 0.000
8 Upstream stormwater discharges/runoff 0.000 0.000 0.000 0.000 0.000 Src Wtr Protcn-3 3 3–Source Water Protection Program 0.000 0.000 0.000 0.000 0.000
6–Human access / activities within watershed 9 Surface water intake structures 0.000 0.000 0.000 0.000 0.000 Src Wtr Asmnt-2 2 2–Source Water Assessment 0.000 0.000 0.000 0.000 0.000
7–Upstream wastewater discharges
8–Upstream stormwater discharges/runoff Total Score by Stream/River Source 0.000 0.000 0.000 0.000 0.000
9–Surface water intake structures
0.0500.1500.2500.3500.4500.5500.6500.7500.8500.950
0.0000.1000.2000.3000.4000.5000.6000.7000.8000.9001.000
No. 4 No. 3 No. 2 No. 1
Part B: Water Source –
II. Surface Water - Lake or Impoundment
No. 1 No. 2 No. 3 No. 4 Total Weighted No. 1 No. 2 No. 3 No. 4 Total Weighted
B.II. Summary by Lake/Impoundment Source
Item Score – Item Score –
No. Component Score Score Score Score Part B.II. No. Component Score Score Score Score Part B.II.
2–Source Water Assessment
2 Source Water Assessment 0.000 0.000 0.000 0.000 0.000 Wtr Intake-9 9 9–Water intake structures 0.000 0.000 0.000 0.000 0.000
3–Source Water Protection Program 3 Source Water Protection Program 0.000 0.000 0.000 0.000 0.000 Strm Wtr-8 8 8–Upstream stormwater discharges/runoff 0.000 0.000 0.000 0.000 0.000
4 Management of land use and activities 0.000 0.000 0.000 0.000 0.000 WW Dschrg-7 7 7–Upstream wastewater discharges 0.000 0.000 0.000 0.000 0.000
4–Management of land use and activities 5 Native and domestic animals in watershed 0.000 0.000 0.000 0.000 0.000 Human access-6 6 6–Human access / activities within watershed 0.000 0.000 0.000 0.000 0.000
6 Human access / activities within watershed 0.000 0.000 0.000 0.000 0.000 Animals-5 5 5–Native and domestic animals in watershed 0.000 0.000 0.000 0.000 0.000
5–Native and domestic animals in watershed 7 Upstream wastewater discharges 0.000 0.000 0.000 0.000 0.000 Lnd Use Mngmnt-4 4 4–Management of land use and activities 0.000 0.000 0.000 0.000 0.000
8 Upstream stormwater discharges/runoff 0.000 0.000 0.000 0.000 0.000 Src Wtr Protcn-3 3 3–Source Water Protection Program 0.000 0.000 0.000 0.000 0.000
6–Human access / activities within watershed
9 Water intake structures 0.000 0.000 0.000 0.000 0.000 Src Wtr Asmnt-2 2 2–Source Water Assessment 0.000 0.000 0.000 0.000 0.000
7–Upstream wastewater discharges
8–Upstream stormwater discharges/runoff
Total Score by Lake/Reservoir Source 0.000 0.000 0.000 0.000 0.000
9–Water intake structures
0.0500.1500.2500.3500.4500.5500.6500.7500.8500.950
0.0000.1000.2000.3000.4000.5000.6000.7000.8000.9001.000
No. 4 No. 3 No. 2 No. 1
Part B: Water Source –
III. Ground Water - Wells
No. 1 No. 2 No. 3 No. 4 Total Weighted No. 1 No. 2 No. 3 No. 4 Total Weighted
B.III. Summary by Well Source
Item Score – Item Score –
No. Component Score Score Score Score Part B.III. No. Component Score Score Score Score Part B.III.
3–Source Water Assessment
3 Source Water Assessment 0.000 0.000 0.000 0.000 0.000 Histrcl Contmntn-10 10 10–Historical Microbiological Contamination 0.000 0.000 0.000 0.000 0.000
4–Source Water Protection Program 4 Source Water Protection Program 0.000 0.000 0.000 0.000 0.000 Well Constr Above-9 9 9–Well construction - above ground 0.000 0.000 0.000 0.000 0.000
5 Management of land use and activities / Influence 0.000 0.000 0.000 0.000 0.000 Well Constr Below-8 8 8–Well construction - below ground 0.000 0.000 0.000 0.000 0.000
5–Management of land use and activities /
Influence 6 Aquifer type 0.000 0.000 0.000 0.000 0.000 Microb Contmnts-7 7 7–Potential microbial contaminants 0.000 0.000 0.000 0.000 0.000
7 Potential microbial contaminants 0.000 0.000 0.000 0.000 0.000 Aquifer Type-6 6 6–Aquifer type 0.000 0.000 0.000 0.000 0.000
6–Aquifer type 8 Well construction - below ground 0.000 0.000 0.000 0.000 0.000 Lnd Use Mngmnt-5 5 5–Management of land use and activities / Influence 0.000 0.000 0.000 0.000 0.000
9 Well construction - above ground 0.000 0.000 0.000 0.000 0.000 Src Wtr Protcn-4 4 4–Source Water Protection Program 0.000 0.000 0.000 0.000 0.000
7–Potential microbial contaminants 10 Historical Microbiological Contamination 0.000 0.000 0.000 0.000 0.000 Src Wtr Asmnt-3 3 3–Source Water Assessment 0.000 0.000 0.000 0.000 0.000
8–Well construction - below ground
9–Well construction - above ground
Total Score by Well Source 0.000 0.000 0.000 0.000 0.000
10–Historical Microbiological Contamination
0.0500.1500.2500.3500.4500.5500.6500.7500.8500.950
0.0000.1000.2000.3000.4000.5000.6000.7000.8000.9001.000
No. 4 No. 3 No. 2 No. 1
Part B: Water Source –
IV. Ground Water - Springs (includes Infiltration Galleries)
No. 1 No. 2 No. 3 No. 4 Total Weighted No. 1 No. 2 No. 3 No. 4 Total Weighted
B.IV. Summary by Spring Source
Score – Score –
No. Component Score Score Score Score Part B.IV. No. Component Score Score Score Score Part B.IV.
3 Source Water Assessment 0.000 0.000 0.000 0.000 0.000 Histrcl Contmntn-10 10 10–Historical Microbiological Contamination 0.000 0.000 0.000 0.000 0.000
4–Source Water Protection Program 4 Source Water Protection Program 0.000 0.000 0.000 0.000 0.000 Sprng Constr-9 9 9–Construction of spring collection facilities 0.000 0.000 0.000 0.000 0.000
5 Management of land use and activities / Influence 0.000 0.000 0.000 0.000 0.000 Sprng Protcn-8 8 8–Spring/collector area protection 0.000 0.000 0.000 0.000 0.000
6 Geologic formation feeding spring 0.000 0.000 0.000 0.000 0.000 Microb Contmnts-7 7 7–Potential microbial contaminants 0.000 0.000 0.000 0.000 0.000
7 Potential microbial contaminants 0.000 0.000 0.000 0.000 0.000 Geologic Frmtn-6 6 6–Geologic formation feeding spring 0.000 0.000 0.000 0.000 0.000
6–Geologic formation feeding spring 8 Spring/collector area protection 0.000 0.000 0.000 0.000 0.000 Lnd Use Mngmnt-5 5 5–Management of land use and activities / Influence 0.000 0.000 0.000 0.000 0.000
9 Construction of spring collection facilities 0.000 0.000 0.000 0.000 0.000 Src Wtr Protcn-4 4 4–Source Water Protection Program 0.000 0.000 0.000 0.000 0.000
10 Historical Microbiological Contamination 0.000 0.000 0.000 0.000 0.000 Src Wtr Asmnt-3 3 3–Source Water Assessment 0.000 0.000 0.000 0.000 0.000
8–Spring/collector area protection
Total Score by Spring Source 0.000 0.000 0.000 0.000 0.000
10–Historical Microbiological Contamination
0.0500.1500.2500.3500.4500.5500.6500.7500.8500.950
0.0000.1000.2000.3000.4000.5000.6000.7000.8000.9001.000
No. 4 No. 3 No. 2 No. 1
Part B - Total Weighted Score - All Sources 0.000
8/7/2012
Summary of Scores
Part C: Treatment
Sum of Percent of Annual Supply for All Treatment = 0
Part C: Treatment –
I. SW Treatment–Disinfection/Corrosion Control Trmnt Only
No. 1 No. 2 No. 3 No. 4 Total Weighted No. 1 No. 2 No. 3 No. 4 Total Weighted
C.I. Summary by SW Treatment - No Filtration
Item Score – Item Score –
No. Component Score Score Score Score Part C.I. No. Component Score Score Score Score Part C.I.
4–Treated Water Quality-Turbidity-Unfiltered
Supply
4 Treated Water Quality-Turbidity-Unfiltered Supply 0.000 0.000 0.000 0.000 0.000 Cross-Connctns-12 12 12–Cross-connections 0.000 0.000 0.000 0.000 0.000
5 Disinfection - Water Quality 0.000 0.000 0.000 0.000 0.000 Turbid Monitor-11 11 11–Turbidity monitoring/alarms 0.000 0.000 0.000 0.000 0.000
5–Disinfection - Water Quality
6 Disinfection - Type 0.000 0.000 0.000 0.000 0.000 Corrsn Cntrl Trmnt-10 10 10–Treatment for corrosion control 0.000 0.000 0.000 0.000 0.000
7 Disinfection - Facilities and Equipment 0.000 0.000 0.000 0.000 0.000 Flow Rate Cntrl-9 9 9–Flow Rate Control - Treatment System 0.000 0.000 0.000 0.000 0.000
6–Disinfection - Type
8 Disinfection System Monitoring and Alarms 0.000 0.000 0.000 0.000 0.000 Disinfctn Monitor-8 8 8–Disinfection System Monitoring and Alarms 0.000 0.000 0.000 0.000 0.000
9 Flow Rate Control - Treatment System 0.000 0.000 0.000 0.000 0.000 Disinfctn Facil Equip-7 7 7–Disinfection - Facilities and Equipment 0.000 0.000 0.000 0.000 0.000
7–Disinfection - Facilities and Equipment
10 Treatment for corrosion control 0.000 0.000 0.000 0.000 0.000 Disinfctn Type-6 6 6–Disinfection - Type 0.000 0.000 0.000 0.000 0.000
11 Turbidity monitoring/alarms 0.000 0.000 0.000 0.000 0.000 Disinfctn Wtr Quality-5 5 5–Disinfection - Water Quality 0.000 0.000 0.000 0.000 0.000
8–Disinfection System Monitoring and Alarms 12 Cross-connections 0.000 0.000 0.000 0.000 0.000 Wtr Turbidity-4 4 4–Treated Water Quality-Turbidity-Unfiltered Supply 0.000 0.000 0.000 0.000 0.000
9–Flow Rate Control - Treatment System
Total Score by SW Treatment Facility -No Filtration 0.000 0.000 0.000 0.000 0.000
10–Treatment for corrosion control
11–Turbidity monitoring/alarms
12–Cross-connections
0.0500.1500.2500.3500.4500.5500.6500.7500.8500.950
0.0000.1000.2000.3000.4000.5000.6000.7000.8000.9001.000
No. 4 No. 3 No. 2 No. 1
Part C: Treatment –
II. SW Treatment-Filtration/Disinfection/Corrosion Control
No. 1 No. 2 No. 3 No. 4 Total Weighted No. 1 No. 2 No. 3 No. 4 Total
C.II. Summary by SW Treatment - Filtration Item Score – Item Weighted
No. Component Score Score Score Score Part C.II. No. Component Score Score Score Score Score
2–Treated water quality–turbidity of filtered supply
2 Treated water quality–turbidity of filtered supply 0.000 0.000 0.000 0.000 0.000 Cross-Connctns-14 14 14–Cross-connections 0.000 0.000 0.000 0.000 0.000
3–Disinfection - Water Quality
3 Disinfection - Water Quality 0.000 0.000 0.000 0.000 0.000 Waste Wtr Recycle-13 13 13–Filter waste backwash water recycle 0.000 0.000 0.000 0.000 0.000
4–Disinfection - Type 4 Disinfection - Type 0.000 0.000 0.000 0.000 0.000 Filtration-12 12 12–Filtration 0.000 0.000 0.000 0.000 0.000
5 Disinfection - Facilities and Equipment 0.000 0.000 0.000 0.000 0.000 Mix/Floc/Sedm-11 11 11–Rapid mixing, flocculation and settling 0.000 0.000 0.000 0.000 0.000
5–Disinfection - Facilities and Equipment
6 Disinfection System Monitoring and Alarms 0.000 0.000 0.000 0.000 0.000 Chem Cntrl-10 10 10–Control of chemical feed systems 0.000 0.000 0.000 0.000 0.000
6–Disinfection System Monitoring and Alarms 7 Flow Rate Control - Treatment System 0.000 0.000 0.000 0.000 0.000 Turbid Monitor-9 9 9–Turbidity monitoring/alarms 0.000 0.000 0.000 0.000 0.000
8 Treatment for corrosion control 0.000 0.000 0.000 0.000 0.000 Corrsn Cntrl Trmnt-8 8 8–Treatment for corrosion control 0.000 0.000 0.000 0.000 0.000
7–Flow Rate Control - Treatment System
9 Turbidity monitoring/alarms 0.000 0.000 0.000 0.000 0.000 Flow Rate Cntrl-7 7 7–Flow Rate Control - Treatment System 0.000 0.000 0.000 0.000 0.000
8–Treatment for corrosion control 10 Control of chemical feed systems 0.000 0.000 0.000 0.000 0.000 Disinfctn Monitor-6 6 6–Disinfection System Monitoring and Alarms 0.000 0.000 0.000 0.000 0.000
9–Turbidity monitoring/alarms 11 Rapid mixing, flocculation and settling 0.000 0.000 0.000 0.000 0.000 Disinfctn Facil Equip-5 5 5–Disinfection - Facilities and Equipment 0.000 0.000 0.000 0.000 0.000
12 Filtration 0.000 0.000 0.000 0.000 0.000 Disinfctn Type-4 4 4–Disinfection - Type 0.000 0.000 0.000 0.000 0.000
10–Control of chemical feed systems 13 Filter waste backwash water recycle 0.000 0.000 0.000 0.000 0.000 Disinfctn Wtr Quality-3 3 3–Disinfection - Water Quality 0.000 0.000 0.000 0.000 0.000
11–Rapid mixing, flocculation and settling 14 Cross-connections 0.000 0.000 0.000 0.000 0.000 Wtr Turbidity-2 2 2–Treated water quality–turbidity of filtered supply 0.000 0.000 0.000 0.000 0.000
12–Filtration
Total Score by SW Treatment Facility - Filtration 0.000 0.000 0.000 0.000 0.000
13–Filter waste backwash water recycle
14–Cross-connections
0.0500.1500.2500.3500.4500.5500.6500.7500.8500.950
0.0000.1000.2000.3000.4000.5000.6000.7000.8000.9001.000
No. 4 No. 3 No. 2 No. 1
Part C: Treatment –
III. Grnd Water – Disinfection/Corrosion Control Trmnt Only
No. 1 No. 2 No. 3 No. 4 Total Weighted No. 1 No. 2 No. 3 No. 4 Total Weighted
C.III. Summary by GW Treatment-Disinfection Only Item Score – Item Score –
No. Component Score Score Score Score Part C.III. No. Component Score Score Score Score Part C.III.
4–Disinfection - Residual Concentration
4 Disinfection - Residual Concentration 0.000 0.000 0.000 0.000 0.000 Cross-Connctns-11 11 11–Cross-connections 0.000 0.000 0.000 0.000 0.000
5 Disinfection - Type 0.000 0.000 0.000 0.000 0.000 Turbid Monitor-10 10 10–Turbidity monitoring/alarms 0.000 0.000 0.000 0.000 0.000
5–Disinfection - Type 6 Disinfection - Facilities and Equipment 0.000 0.000 0.000 0.000 0.000 Corrsn Cntrl Trmnt-9 9 9–Treatment for corrosion control 0.000 0.000 0.000 0.000 0.000
7 Disinfection System Monitoring and Alarms 0.000 0.000 0.000 0.000 0.000 Flow Rate Cntrl-8 8 8–Flow Rate Control - Treatment System 0.000 0.000 0.000 0.000 0.000
6–Disinfection - Facilities and Equipment 8 Flow Rate Control - Treatment System 0.000 0.000 0.000 0.000 0.000 Disinfctn Monitor-7 7 7–Disinfection System Monitoring and Alarms 0.000 0.000 0.000 0.000 0.000
9 Treatment for corrosion control 0.000 0.000 0.000 0.000 0.000 Disinfctn Facil Equip-6 6 6–Disinfection - Facilities and Equipment 0.000 0.000 0.000 0.000 0.000
10 Turbidity monitoring/alarms 0.000 0.000 0.000 0.000 0.000 Disinfctn Type-5 5 5–Disinfection - Type 0.000 0.000 0.000 0.000 0.000
7–Disinfection System Monitoring and Alarms
11 Cross-connections 0.000 0.000 0.000 0.000 0.000 Resid Conc-4 4 4–Disinfection - Residual Concentration 0.000 0.000 0.000 0.000 0.000
8–Flow Rate Control - Treatment System
Total Score by GW Treatment Facility - Disinfection Only 0.000 0.000 0.000 0.000 0.000
9–Treatment for corrosion control
10–Turbidity monitoring/alarms
11–Cross-connections
0.0500.1500.2500.3500.4500.5500.6500.7500.8500.950
0.0000.1000.2000.3000.4000.5000.6000.7000.8000.9001.000
No. 4 No. 3 No. 2 No. 1
Part C: Treatment –
IV. Ground Water Supply – Other Treatment Types
No. 1 No. 2 No. 3 No. 4 Total Weighted No. 1 No. 2 No. 3 No. 4 Total Weighted
C.IV. Summary by GW Treatment - Other Types
Score – Score –
No. Component Score Score Score Score Part C.IV. No. Component Score Score Score Score Part C.IV.
4–Disinfection - Residual Concentration
4 Disinfection - Residual Concentration 0.000 0.000 0.000 0.000 0.000 Cross-Connctns-13 13 13–Cross-connections 0.000 0.000 0.000 0.000 0.000
5–Disinfection - Type
5 Disinfection - Type 0.000 0.000 0.000 0.000 0.000 Aeratn/Air Strip-12 12 12–Aeration or air stripping 0.000 0.000 0.000 0.000 0.000
6–Disinfection - Facilities and Equipment 6 Disinfection - Facilities and Equipment 0.000 0.000 0.000 0.000 0.000 Filtration-11 11 11–Filtration treatment 0.000 0.000 0.000 0.000 0.000
7 Disinfection System Monitoring and Alarms 0.000 0.000 0.000 0.000 0.000 Turbid Monitor-10 10 10–Turbidity monitoring/alarms 0.000 0.000 0.000 0.000 0.000
7–Disinfection System Monitoring and Alarms
8 Flow Rate Control - Treatment System 0.000 0.000 0.000 0.000 0.000 Corrsn Cntrl Trmnt-9 9 9–Corrosion control treatment 0.000 0.000 0.000 0.000 0.000
8–Flow Rate Control - Treatment System 9 Corrosion control treatment 0.000 0.000 0.000 0.000 0.000 Flow Rate Cntrl-8 8 8–Flow Rate Control - Treatment System 0.000 0.000 0.000 0.000 0.000
10 Turbidity monitoring/alarms 0.000 0.000 0.000 0.000 0.000 Disinfctn Monitor-7 7 7–Disinfection System Monitoring and Alarms 0.000 0.000 0.000 0.000 0.000
9–Corrosion control treatment
11 Filtration treatment 0.000 0.000 0.000 0.000 0.000 Disinfctn Facil Equip-6 6 6–Disinfection - Facilities and Equipment 0.000 0.000 0.000 0.000 0.000
10–Turbidity monitoring/alarms 12 Aeration or air stripping 0.000 0.000 0.000 0.000 0.000 Disinfctn Type-5 5 5–Disinfection - Type 0.000 0.000 0.000 0.000 0.000
13 Cross-connections 0.000 0.000 0.000 0.000 0.000 Resid Conc-4 4 4–Disinfection - Residual Concentration 0.000 0.000 0.000 0.000 0.000
11–Filtration treatment
12–Aeration or air stripping Total Score by GW Treatment Facility - Other Types 0.000 0.000 0.000 0.000 0.000
13–Cross-connections
0.050 0.150 0.250 0.350 0.450 0.550 0.650 0.750 0.850 0.950
0.000 0.100 0.200 0.300 0.400 0.500 0.600 0.700 0.800 0.900 1.000
No. 4 No. 3 No. 2 No. 1
Part C - Total Weighted Score - All Sources 0.000
8/7/2012
Summary of Scores
Part D: Pumping and Storage
Distribution Wells Treated Raw
Sum of Percent of Annual Supply for Pumps = 0 0 0 0
Part D: Pumping and Storage –
I. Pumping Facilities
No. 1 No. 2 No. 3 No. 4 Total Weighted No. 1 No. 2 No. 3 No. 4 Total Weighted
D.I. Summary by Pumping Facility
Item Score – Item Score –
No. Component Score Score Score Score Part D.I. No. Component Score Score Score Score Part D.I.
3–Type of pumping
facility 3 Type of pumping facility 0.000 0.000 0.000 0.000 0.000 Maint/Repairs-10 10 10–Maintenance and Repairs 0.000 0.000 0.000 0.000 0.000
4 Pump station capacity 0.000 0.000 0.000 0.000 0.000 Pump Control-9 9 9–Control of pumps 0.000 0.000 0.000 0.000 0.000
4–Pump station
capacity 5 Emergency power provisions 0.000 0.000 0.000 0.000 0.000 Runoff/Flood-8 8 8–Susceptibility to runoff or flooding 0.000 0.000 0.000 0.000 0.000
6 Physical facility 0.000 0.000 0.000 0.000 0.000 Cross-connctns-7 7 7–Potential cross-connections 0.000 0.000 0.000 0.000 0.000
5–Emergency power 7 Potential cross-connections 0.000 0.000 0.000 0.000 0.000 Physical Facil-6 6 6–Physical facility 0.000 0.000 0.000 0.000 0.000
provisions
8 Susceptibility to runoff or flooding 0.000 0.000 0.000 0.000 0.000 Emergncy Pwr-5 5 5–Emergency power provisions 0.000 0.000 0.000 0.000 0.000
9 Control of pumps 0.000 0.000 0.000 0.000 0.000 Capacity-4 4 4–Pump station capacity 0.000 0.000 0.000 0.000 0.000
6–Physical facility
10 Maintenance and Repairs 0.000 0.000 0.000 0.000 0.000 Type Pump Facil-3 3 3–Type of pumping facility 0.000 0.000 0.000 0.000 0.000
7–Potential cross-
connections
8–Susceptibility to Total Score by Pumping Facility 0.000 0.000 0.000 0.000 0.000
runoff or flooding
9–Control of pumps
10–Maintenance and
Repairs
0.050 0.150 0.250 0.350 0.450 0.550 0.650 0.750 0.850 0.950
0.000 0.100 0.200 0.300 0.400 0.500 0.600 0.700 0.800 0.900 1.000
No. 4 No. 3 No. 2 No. 1
Sum of Percent of Annual Supply for All Storage = 0 (If System Has Storage, Value Must Equal 100)
Part D: Pumping and Storage –
II. Storage Facilities
No. 1 No. 2 No. 3 No. 4 Total Weighted No. 1 No. 2 No. 3 No. 4 Total Weighted
D.II. Summary by Storage Facility
Item Score – Item Score –
No. Component Score Score Score Score Part D.II. No. Component Score Score Score Score Part D.II.
3–Type of storage facility
3 Type of storage facility 0.000 0.000 0.000 0.000 0.000 Cleaning-12 12 12–Tank cleaning 0.000 0.000 0.000 0.000 0.000
4–Holes in roof, walls or door; tank cover 4 Holes in roof, walls or door; tank cover 0.000 0.000 0.000 0.000 0.000 Maintenance-11 11 11–Tank maintenance 0.000 0.000 0.000 0.000 0.000
5 Air vents 0.000 0.000 0.000 0.000 0.000 Controls-10 10 10–Storage controls 0.000 0.000 0.000 0.000 0.000
5–Air vents 6 Access openings 0.000 0.000 0.000 0.000 0.000 Capacity-9 9 9–Storage capacity 0.000 0.000 0.000 0.000 0.000
7 Is tank site susceptible to runoff or flooding? 0.000 0.000 0.000 0.000 0.000 Ovrflw/Drn-8 8 8–Tank overflow/drain lines 0.000 0.000 0.000 0.000 0.000
6–Access openings 8 Tank overflow/drain lines 0.000 0.000 0.000 0.000 0.000 Runoff/Flood-7 7 7–Is tank site susceptible to runoff or flooding? 0.000 0.000 0.000 0.000 0.000
9 Storage capacity 0.000 0.000 0.000 0.000 0.000 Access Opngs-6 6 6–Access openings 0.000 0.000 0.000 0.000 0.000
7–Is tank site susceptible to runoff or flooding? 10 Storage controls 0.000 0.000 0.000 0.000 0.000 Air Vents-5 5 5–Air vents 0.000 0.000 0.000 0.000 0.000
11 Tank maintenance 0.000 0.000 0.000 0.000 0.000 Holes/Cracks-4 4 4–Holes in roof, walls or door; tank cover 0.000 0.000 0.000 0.000 0.000
8–Tank overflow/drain lines
12 Tank cleaning 0.000 0.000 0.000 0.000 0.000 Storage Type-3 3 3–Type of storage facility 0.000 0.000 0.000 0.000 0.000
9–Storage capacity
10–Storage controls
11–Tank maintenance
Total Score by Storage Facility 0.000 0.000 0.000 0.000 0.000
12–Tank cleaning
0.0500.1500.2500.3500.4500.5500.6500.7500.8500.950
0.0000.1000.2000.3000.4000.5000.6000.7000.8000.9001.000
No. 4 No. 3 No. 2 No. 1
8/7/2012
Summary of Scores
Part E: Transmission and Distribution
Sum of Percent of Annual Supply for All Raw Water Pipelines = 0
Sum of Percent of Annual Supply for All Treated Water Pipelines = 0
–
Part E: Transmission and Distribution
I. Transmission Pipelines
No. 1 No. 2 No. 3 No. 4 Total Weighted No. 1 No. 2 No. 3 No. 4 Total
E.I. Summary by Transmission Pipeline
Score – Weighted
Item Score Score Score Score Part E.I. Item Score Score Score Score Score
3–Materials of No. Component No. Component Raw Raw Raw Raw
construction
3 Materials of construction 0.000 0.000 0.000 0.000 0.000 Records-11 11 11–System records 0.000 0.000 0.000 0.000 0.000
4–Pressure and pressure
zones 4 Pressure and pressure zones 0.000 0.000 0.000 0.000 0.000 Contam Haz-10 10 10–Possible contamination hazards 0.000 0.000 0.000 0.000 0.000
5 Integrity of pipeline joints 0.000 0.000 0.000 0.000 0.000 Srvc Lines-9 9 9–Service lines 0.000 0.000 0.000 0.000 0.000
5–Integrity of pipeline
joints 6 Maintenance 0.000 0.000 0.000 0.000 0.000 Structures-8 8 8–Pipeline structures 0.000 0.000 0.000 0.000 0.000
7 Repairs 0.000 0.000 0.000 0.000 0.000 Repairs-7 7 7–Repairs 0.000 0.000 0.000 0.000 0.000
6–Maintenance 8 Pipeline structures 0.000 0.000 0.000 0.000 0.000 Maintenance-6 6 6–Maintenance 0.000 0.000 0.000 0.000 0.000
9 Service lines 0.000 0.000 0.000 0.000 0.000 Joints-5 5 5–Integrity of pipeline joints 0.000 0.000 0.000 0.000 0.000
7–Repairs 10 Possible contamination hazards 0.000 0.000 0.000 0.000 0.000 Pressure/Zones-4 4 4–Pressure and pressure zones 0.000 0.000 0.000 0.000 0.000
11 System records 0.000 0.000 0.000 0.000 0.000 Materials-3 3 3–Materials of construction 0.000 0.000 0.000 0.000 0.000
8–Pipeline structures
Total Score by Pumping Facility 0.000 0.000 0.000 0.000 0.000
9–Service lines
10–Possible
contamination hazards
11–System records
0.000.050.100.150.200.250.300.350.400.450.500.550.600.650.700.750.800.850.900.951.00
No. 4 No. 3 No. 2 No. 1
–
Part E: Transmission and Distribution
II. Distribution System
No. 1 No. 2 No. 3 No. 4 Total Weighted No. 1 No. 2 No. 3 No. 4 Total
E.II. Summary for Distribution System Item Score – Item Weighted
No. Component Score Score Score Score Part E.II. No. Component Score Score Score Score Score
2–Materials of construction 2 Materials of construction 0.000 Resid Disinfctn-12 12 12–Residual disinfection 0.000 0.000 0.000 0.000 0.000
3 Pressure and pressure zones 0.000 Records-11 11 11–System records 0.000 0.000 0.000 0.000 0.000
3–Pressure and pressure zones 4 Maintenance 0.000 Cross-Connctn-10 10 10–Cross-connections - backflow prevention 0.000 0.000 0.000 0.000 0.000
5 Repairs 0.000 Dead-ends-9 9 9–Dead-ends and low-flow areas 0.000 0.000 0.000 0.000 0.000
4–Maintenance 6 Service lines and meters 0.000 Contam Haz-8 8 8–Possible contamination hazards 0.000 0.000 0.000 0.000 0.000
7 New construction of distribution pipelines and related facilities 0.000 New Constr-7 7 7–New construction of distribution pipelines and related facilities
0.000 0.000 0.000 0.000 0.000
5–Repairs 8 Possible contamination hazards 0.000 Srvc Lines-6 6 6–Service lines and meters 0.000 0.000 0.000 0.000 0.000
9 Dead-ends and low-flow areas 0.000 Repairs-5 5 5–Repairs 0.000 0.000 0.000 0.000 0.000
6–Service lines and meters 10 Cross-connections - backflow prevention 0.000 Maintenance-4 4 4–Maintenance 0.000 0.000 0.000 0.000 0.000
11 System records 0.000 Pressure/Zones-3 3 3–Pressure and pressure zones 0.000 0.000 0.000 0.000 0.000
7–New construction of distribution pipelines and 12 Residual disinfection 0.000 Materials-2 2 2–Materials of construction 0.000 0.000 0.000 0.000 0.000
related facilities
8–Possible contamination hazards
Total Score for Distribution System 0.000
9–Dead-ends and low-flow areas
10–Cross-connections - backflow prevention
11–System records
12–Residual disinfection
0.05 0.15 0.25 0.35 0.45 0.55 0.65 0.75 0.85 0.95
0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00
8/7/2012
Summary of Scores
Part F: Water Quality Monitoring
Part F: Water Quality Monitoring –
No. 1 No. 2 No. 3 No. 4 Total Weighted No. 1 No. 2 No. 3 No. 4 Total Weighted
F. Summary for Water Quality Monitoring
Item Score – Item Score –
No. Component Score Score Score Score Part F. No. Component Score Score Score Score Part F.
1–Source water 1 Source water monitoring 0.000 Handling/Analysis-4 4 4–Microbiological sample handling and analysis 0.000
monitoring 2 Treated water monitoring (prior to entering the distribution system) 0.000 Distrb Wtr Smplng-3 3 3–Distributed water sampling 0.000
3 Distributed water sampling 0.000 Treat Wtr Monitor-2 2 2–Treated water monitoring (prior to entering the distribution system) 0.000
4 Microbiological sample handling and analysis 0.000 Src Wtr Monitor-1 1 1–Source water monitoring 0.000
2–Treated water
monitoring (prior to
entering the distribution
system)
3–Distributed water
sampling Total Score for Water Quality Monitoring 0.000 0.000 0.000 0.000 0.000
4–Microbiological
sample handling and
analysis
0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00
8/7/2012
Total System Scores — 0
Survey Weighted
Item No. Category Total Score Comments Total Score for Water System 0.000
F. Water
Quality
B. Water Source 0.000 F. Monitoring 0.091 0.091 0.186 0.000 0.000 0.000 0.000
C. Treatment 0.000 E. II. E. II. Distribution 0.184 0.184 0.375 0.000 0.000 0.000 0.000
D. I. Pumping 0.000 E. I. E. I. Transmission 0.103 0.000 0.000 0.000 0.000 0.000 0.000
D. II. Storage 0.000 D. II. D. II. Storage 0.109 0.000 0.000 0.000 0.000 0.000 0.000
E. I. Transmission 0.000 D. I. D. I. Pumping 0.086 0.000 0.000 0.000 0.000 0.000 0.000
E. II. Distribution 0.000 C. C. Treatment 0.213 0.000 0.000 0.000 0.000 0.000 0.000
Water Quality B. Water
F. Monitoring 0.000 B. Source 0.215 0.215 0.438 0.000 0.000 0.000 0.000
Total Score for Water System 0.000
Summary of Scores for Total Water System
B. Water Source 0.000
C. Treatment 0.000
D. I. Pumping 0.000
D. II. Storage 0.000
E. I. Transmission 0.000
E. II. Distribution 0.000
F. Water Quality
Monitoring 0.000
Total Score for Water System 0.000
0.000 0.100 0.200 0.300 0.400 0.500 0.600 0.700 0.800 0.900 1.000
Score
8/7/2012
