Page 12: Guidance For Providing Safe Drinking Water in Areas of Federal Jurisdiction – Version 2

Appendix F: Watermain Break Report (Sample)

General

  • Date and time break reported:
  • Time when water was shut off:
  • Time when water was turned on:
  • Properties affected:
  • Air temperature:
  • Repair by:
  • Property damage:

Location

  • Nearest property address:
  • Distance from nearest property line:
  • Distance from nearest intersection:
  • Northing and easting:
  • Isolation valves operated:

Physical Data

  • Pipe diameter:
  • Pipe material:
  • Year of installation:
  • Pipe wall thickness or pipe class:
  • Type of lining:
  • Type of joint:
  • Type of water service:
  • Normal operating pressure:
  • Under boulevard or road:
  • Depth of cover:
  • Depth of frost:
  • Type of native soil:
  • Type of backfill:
  • Soil resistivity:
  • Soil sample collected (Yes / No):
  • Pipe sample collected (Yes / No):

Type of Failure

  • Circumferential break
  • Longitudinal break
  • Split bell
  • Corrosion pit hole
  • Leaking joint
  • Leaking valve
  • Leaking service connection

Probable Cause of Failure

  • Corrosion
  • Ground frost
  • Joint failure
  • Disturbance (third party)
  • High pressure
  • Frozen pipe

Type of Repair

  • Repair clamp
  • Replace pipe section
  • Replace valve
  • Replace service connection
  • Anode installed
  • Repair joint
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