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
