Page 10: Guidance For Providing Safe Drinking Water in Areas of Federal Jurisdiction – Version 2

Appendix D: Sample Well Assessment Form

Part I: Well System Information

  • Site Location Identification
  • Description of Well Location
  • How Many Wells on Site?
  • Popoulation Being Served
  • Water Meter
    • Yes
    • No
  • Well Operator Name
  • Well Operator Telephone
  • Well Operator Address

Part II: Well Construction Information

  • Well Driller'S Name, Company, Address
  • Postal Code
  • Well Driller's Telephone Number
  • Date Well Originally Contructed
  • Date of Last Reconstruction
  • Type of Well
    • Drilled
    • Dug
    • Other (Specify)
  • Well Log Available?
    • Yes
    • No
    Attach Copy If Yes
  • Depth of Well (m)
  • Diameter of Well (m)
  • Well Capacity (L/s)
  • Wellhead Enclosure
    • Pump Hose
    • Manhole
    • Other (Specify)
  • Pump Age
  • Average Pumping Rate (L/s)
  • Annual Volume of Water Pumped (L/s)
  • Pumping Capacity (L/s)
  • Type of Storage
    • Tank
    • Resevoir
    • Other (Specify)
  • Storage Capacity (L)

Part III: Hydrogeologic Information

  • Depth to Pumping Water (m or feet)
  • Well Associated With Known Aquifier (If Yes, Give Name)
  • Type of Aquifer
  • Other High Capacity Wells (30L/s) Located Within 300m Radius
  • Annual Rainfall

Part IV: Assessment of Water Quality

  • How Long Has the Water System Been in Existence?
  • Has the Well Ever Been Deepened, Cleaned, Reconstructed?
    • Yes-Why
    • No
  • Have There Ever Been Any Water Quality Problems?
    • Yes - When and what was the cause?
    • No

Indicate results and identified problems for each of the following parameters (10 years).

  • Bacteriological (Coliforms)
  • Disinfection by- Products (Bromodi and Dibromochloromethane, Chloroform)
  • Physical Parameters (pH, Colour, Alkalinity, Conductance, Hardness, Turbidity, Others)
  • Inorganic Parameters (Nitrates, Fluoride, Sulfates, Ammonia, Chloride, Nitrogen, Others)
  • Metals (Calcium, Iron, Magnesium, Manganese, Sodium)

Part V: Water Treatment Information

  • Is the Source Treated?
    • Yes - Type of Treatment
    • No
  • Purpose of Treatment
  • Is Water Chlorinated at Any Point in the Distribution System?
    • Yes
    • No
  • What Type of Chemicals Are Used in the Treatment Process?
  • Completed By
  • Title
  • Signature
  • Date
  • Organization

(Canada Customs and Revenue Agency, 2002)

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