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

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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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