MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY OFFICE OF DRINKING AND MUNICIPAL ASSISTANCE Level 1 Assessment Form For Community Water Supplies Issued under authority of the Safe Drinking Water Act, 1976 PA 399, as amended, MCL 325.1001 et seq., and its Administrative (Act 399). This form must be completed and submitted to the appropriate DEQ District Office as soon as possible, but no than 30 days after the supply triggered the assessment. It should be completed by the Operator In Charge, Water Supply Owner, or a knowledgeable representative of the water system. 1. General Information CWS Name: WSSN: Assessor Name: Assessor Title: Phone Number: E-mail: Trigger Event: Greater Than 5% Total Coliform Positives Failure to Collect All Repeat Samples or Date Assessment Completed: Date Assessment Triggered: 2. Bacteriological Sample Summary (Include all results associated with monitoring period, add additional pages if necessary) Purpose (Routine, Repeat, Result (ND, TC+, Date & Time Location Triggered, EC+, invalid, Collected By Laboratory Construction, interference) Repair) 3. Assessment Questions: Answer each question in Subsections A - G either Yes, No or Not Applicable (NA). Review and evaluate each question for potential causes of contamination. If the answer to any of these questions is unknown, leave blank and indicate on a separate sheet what actions will be taken to determine the necessary information. A. Sample Site Selection and Sample Collection Answer Yes No NA Were the samples collected in accordance with the Sample Site Plan? Was the location and condition of the sample tap sanitary? Were proper sample collection procedures followed? Were the samples submitted to the lab in a timely & acceptable manner? B. Source Wells (if wells are not used check here and go to subsection C) – Answer Yes No NA Do the wells have a proper well cap, sanitary seal and vent screens? Have the wells/pumps undergone any recent repairs or maintenance activities? Is the exposed portion of the casing (including electrical conduit) in good condition? Is the area near the well cap/casing free of insects, bugs, brush and vegetation? Is there standing water or other unsanitary conditions near the wells? Any signs of vandalism to wells or forced entry into well houses?
MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY OFFICE OF DRINKING AND MUNICIPAL ASSISTANCE Level 1 Assessment Form For Community Water Supplies Issued under authority of the Safe Drinking Water Act, 1976 PA 399, as amended, MCL 325.1001 et seq., and its Administrative (Act 399). This form must be completed and submitted to the appropriate DEQ District Office as soon as possible, but no than 30 days after the supply triggered the assessment. It should be completed by the Operator In Charge, Water Supply Owner, or a knowledgeable representative of the water system. 1. General Information CWS Name: WSSN: Assessor Name: Assessor Title: Phone Number: E-mail: Trigger Event: Greater Than 5% Total Coliform Positives or Failure to Collect All Repeat Samples Date Assessment Triggered: Date Assessment Completed: 2. Bacteriological Sample Summary (Include all results associated with monitoring period, add additional pages if necessary) Date & Time Location Purpose (Routine, Repeat, Triggered, Construction, Repair) Result (ND, TC+, EC+, invalid, interference) Collected By Laboratory 3. Assessment Questions: Answer each question in Subsections A - G either Yes, No or Not Applicable (NA). Review and evaluate each question for potential causes of contamination. If the answer to any of these questions is unknown, leave blank and indicate on a separate sheet what actions will be taken to determine the necessary information. A. Sample Site Selection and Sample Collection Answer Yes No NA Were the samples collected in accordance with the Sample Site Plan? Was the location and condition of the sample tap sanitary? Were proper sample collection procedures followed? Were the samples submitted to the lab in a timely & acceptable manner? B. Source – Wells (if wells are not used check here and go to subsection C) Answer Yes No NA Do the wells have a proper well cap, sanitary seal and vent screens? Have the wells/pumps undergone any recent repairs or maintenance activities? Is the exposed portion of the casing (including electrical conduit) in good condition? Is the area near the well cap/casing free of insects, bugs, brush and vegetation? Is there standing water or other unsanitary conditions near the wells? Any signs of vandalism to wells or forced entry into well houses?
Community_Water_-_Level_1_Assessment_517557_7.docx