Fillable Request-investigation-drinking-water-protection-act-editable DWOG PART B

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Request-investigation-drinking-water-protection-act-editable DWOG PART B

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DRINKING WATER OFFICERS’ GUIDE
Page 11 PART B: Requests for Investigation of a Drinking Water Threat
REQUEST FOR A SECTION 29 INVESTIGATION UNDER THE
DRINKING WATER PROTECTION ACT
Name: Date:
Mailing address: Phone Numbers:
Address of well property:
1. Is your water supply or residence located on federal or First Nation Lands �Yes No
Unsure
2. Source of Water
Private Well
Private Surface Water (Provide Name of Stream or Lake) ____________
� Permitted Community Water System (Provide Name) ____________ (if municipal option applicable
please proceed to question 24)
3. Describe the location of your drinking water supply (i.e. well) on your property. (ex. 20 m from
north boundary and 60 m from east boundary of property)
Well Information (If Applicable)
4. Is your well: Drilled Excavated (dug) Driven (sand point) Unsure
5. What year was your well drilled? ______________________ Unsure
6. Name of well driller ___________________________ Unsure
7. Do you have a copy of the well Drillers log (Please attach copy if available)
Yes No Unsure
8. How deep is the well? ____________(meters) Unsure
9. How deep is the water table below the ground? _________________(meters) Unsure
10. Does the well draw water from: Sand and/or gravel aquifer Fractured bedrock Unsure
11. During well construction were there any layers of clay, silt, till or hardpan encountered above
the well screen or well intake? Yes No Unsure
DRINKING WATER OFFICERS’ GUIDE
Page 12 PART B: Requests for Investigation of a Drinking Water Threat
12. Does the well have a secure well cap? Yes No Unsure
13. Does the well have a surface seal? �Yes �No �Unsure
14. Is the well located in an area where there is known flooding or where water can pond?
� Yes � No � Unsure
15. Are there any structures, buildings, material storage, or animals near your well-head? (Please
describe)
16. Is your well-head protected by a covered structure?
17. Has your well been disinfected in the past? (please describe)
18. Any other relevant information about your well? (Please describe)
_____________________________________________________________________________________
19. Have there been any ground water assessments of your well water supply conducted by a
professional hydrogeologist? (Please provide a copy of the report)
_____________________________________________________________________________________
20. Is water stored at your home stored prior to use in a:
� Pressure tank
� Holding tank
� Other _________________________________
� No water storage
_____________________________________________________________________________________
21. What type of material is used for the water distribution pipes?
In your home ____________________________
From your well to your home _______________
From street to your home __________________
_____________________________________________________________________________________
22. Do you currently treat your drinking water supply? � No � Yes,
If yes, please specify method used: � Chlorine � UV � Osmosis � Boiling
� Filtration (specify type) ___________________ � Other ___________________
DRINKING WATER OFFICERS’ GUIDE
Page 13 PART B: Requests for Investigation of a Drinking Water Threat
23. Are any of the following located close to your water well or surface water intake? If so, please
describe and include approximate distance:
_____________________________________________________________________________________
a. Chemical storage (household or agricultural, including pesticides) Distance: _______________meters
_____________________________________________________________________________________
b. Fuel storage (above ground or underground) Distance: _______________meters
_____________________________________________________________________________________
c. Manure storage or application Distance: _______________meters
_____________________________________________________________________________________
d. Livestock Distance: _______________meters
_____________________________________________________________________________________
e. Wildlife Distance: _______________meters
_____________________________________________________________________________________
f. Other wells including abandoned well(s) Distance: _______________meters
_____________________________________________________________________________________
g. Septic systems, (including your own or those on nearby properties) Distance: _______________meters
_____________________________________________________________________________________
h. Major roads, highways, railways, pipelines, drainage ditches Distance: _______________meters
_____________________________________________________________________________________
i. Lake, stream, river, pond or ocean Distance: _______________meters
_____________________________________________________________________________________
j. Landfill, refuse storage, contaminated sites Distance: _______________meters
_____________________________________________________________________________________
k. Other (Specify)
DRINKING WATER OFFICERS’ GUIDE
Page 14 PART B: Requests for Investigation of a Drinking Water Threat
24. Have you noticed any taste, odour and/or appearance changes (colour, cloudiness) to your drinking
water? If so, when did you first notice the change? (Please provide details)
25. Has anyone become ill as a result of drinking the tap water from your home? (Please provide supporting
documentation if possible, including water test reports, medical testing results and/ or doctor’s report).
26. Have there been any water quality tests performed on your drinking water supply (Chemical,
Bacteriological, other)? (Please attach copies of lab reports)
_____________________________________________________________________________________
27. Are you aware if your municipal water supplier has issued a boil water notice or drinking water
advisory? If so, what was the nature of the advisory?
_____________________________________________________________________________________
28. Have you contacted your municipal water supplier about your concerns? If so, what was their
response?
_____________________________________________________________________________________
29. If applicable, please provide municipal contact person you have interacted with on this issue
_____________________________________________________________________________________
30. Other evidence which supports your concern about the safety of your drinking water? (Please
provide specific details and attach any relevant supporting documents.)
_____________________________________________________________________________________
31. What initiated your complaint?
__________________________________________________________________________________________
32. How do you expect your complaint to be resolved?
DRINKING WATER OFFICERS’ GUIDE
Page 15 PART B: Requests for Investigation of a Drinking Water Threat
___________________________________
Name of person requesting an Investigation
(Please Print)
___________________________ _____________
Signature
Date
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Completed 3 July 2020

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