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
- 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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