Document ID: EPA-HQ-OW-2010-0689-0003
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2010-09-13T04:00Z

2011 Drinking Water Infrastructure

Needs Survey and Assessment

U.S. Environmental Protection Agency

	Washington, DC 20460 

Please verify or correct the following information:

	Check if Correct as Printed	Corrected Information

(Fill in only if preprinted information is missing or incorrect)

Name of System (Community): 	(

	Name of Contact for Water System:

(Record name of person completing survey on page 8; may be same person) 

Street Address:

City, State, and Zip: 	(

	Population Served (if wholesale seller, include population of systems
sold to):	(

	Number of Connections (not including those in consecutive systems): 	(

	Total System Design Capacity:     ____________ MGD

Source Water Type (Ground, Surface/GWUDI, etc.): 	  Check All That
Apply: 	 ( Ground 		            (  Surface/GWUDI

                                        ( Purchased Ground 		           
(  Purchased Surface/GWUDI

Ownership Type: 	  Check All That Apply: 	 ( Public	(	Federal Government

                                        (  Native American	(
Investor-Owned or Private

					Non-Profit

	 ( Native Alaskan Village

Public reporting burden for this collection of information is estimated
to average 7.55 hours per response. This estimate includes time for
reviewing the instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the
information collected. Burden means the total time, effort, or financial
resources expended by person(s) to generate, maintain, retain, or
disclose or provide information to or for a Federal Agency. This
includes the time needed to review instructions; develop, acquire,
install, and utilize technology and systems for the purposes of
collecting, validating, and verifying information; adjust the existing
ways to comply with any previously applicable instructions; search data
sources; complete and review the collection of information; and transmit
or otherwise disclose the information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The
OMB control numbers for EPA’s regulations are listed in 40 CFR Part 9
and 48 CFR Chapter 15. 

Send comments on the Agency’s need for this information, the accuracy
of the provided burden estimates, and any suggested methods for
minimizing respondent burden, including through the use of automated
collection techniques to the Director, OPPI, Regulatory Information
Division, U.S. Environmental Protection Agency (1804A), Ariel Rios
Building, 1200 Pennsylvania Ave., NW, Washington, DC 20460; and Office
of Information and Regulatory Affairs, Office of Management and Budget,
725 17th Street, N.W., Washington, DC 20503.

State Use Only

State Reviewer:
________________________________________________________________________
___________	Telephone Number: __________________________

Information provided for this survey can be requested by the public;
however, EPA will not release the names and addresses of respondents.
Also it is our experience that survey information is rarely requested.
Source, Treatment, Storage, and Pumping Inventory

To ensure all potential source, treatment, and storage projects are
considered, it may be helpful to complete some or all of this inventory
table.  However, completion of this table is not required. 

Source Water

Inventory	Needing Replacement	Needing Rehabilitation	New Infrastructure
Needs

Total Number and Capacity of Existing Wells or Springs: 

		Wells (pumps included) or Springs:

		Wells (pumps included) or Springs:

  

			Does your system have additional source water capacity needs to meet
the needs of current users? (check one)

Yes ___	 No ___	______

Total Number and Capacity of Existing Surface Water Sources:         
_____________________________	Existing Surface Water Intakes (excluding
pumps): 

		Existing Surface Water Intakes (excluding pumps): 

         		If yes, how many additional sources are necessary? 

Total Number and Capacity of Existing Pumps (excluding booster pump 

stations):

		Existing Groundwater Pumps (if wells not listed): 

		Existing Groundwater Pumps (if wells not listed): 

	

Existing Raw Surface Water Pumps:

 		Existing Raw Surface Water Pumps: 

	

	Treatment

Inventory	Needing Replacement	Needing Expansion/Upgrading or
Rehabilitation	New Infrastructure Needs

For the sources identified above, enter the number of locations where
the following treatment is applied:

	Disinfection (including booster 

disinfection): 		Disinfection: 	 	Disinfection:		Does your system have
additional treatment needs for provision of additional public health
protection or for aesthetic concerns? (check one)

 

Yes ___ No ___

If yes, what additional treatment is necessary?

Filtration: 		Filtration:		Filtration: 	

	Chemical removal or addition: 

		Chemical treatment: 		Chemical treatment: 	

	Storage and Pump Stations

Inventory	Needing Replacement	Needing Rehabilitation	New Infrastructure
Needs

Total Number and Capacity of Existing Storage Tanks:

 		Number of Existing Elevated or Ground-Level Storage Tanks:

 	________________________	Number of Existing Elevated or Ground-Level
Storage Tanks:

 	_________________________	Does your system have additional storage
capacity and/or booster pumping needs to meet the needs of current
users? (check one) 

Yes 	   No 	_   

If yes, how much additional finished water storage or booster pumping
capacity is necessary?

Total Number and Capacity of Existing Booster Pump Stations: 

		Number of Existing Booster Pump Stations: 

	________________________	Number of Existing Booster Pump Stations: 

	_________________________

	Source, Treatment, Storage, and Pumping Projects

Project

Number	Project Name	Type of Need

(List 1)	Reason for Need

(List 2)	New,

Replace,

ReHab, Expand/

upgrade	Current

or

Future	Reg or Secondary Purpose

(List 3)

	Design Capacity (MG, MGD, kW)	Number Needed

(if applicable)	Cost Estimate

(if available)	Date of Cost Estimate

(Month/

Year)	Documen-

tation

(List 4)

Ex. 1	Replace Wells 3 and 8 

at 0.5 MGD each	R1	A1	R	C	4A	0.5	2	-	-	6, 10

Ex. 2	Rehab Treatment Plant and Booster Station	T10	A1,A6	H	F	1A	5.0	1
$6,027,000	12/2009	4

1000

	1001

	1002

	1003

	1004

	1005

	1006

	1007

	

If a project is coded 2G for “climate readiness” from List 3, please
refer to page 7 for supplemental questions. 

If you have more source, treatment, storage, or pumping projects check
this box ( and continue on a supplemental sheet (included in this
package or downloadable at www.DWNeeds.com). Project numbers for these
types of projects are 1000-1999, and should be numbered in sequence.

EPA requires documentation of all projects provided.  Applicable types
of documentation are presented in List 4 of the Lists of Codes.

Use only existing documentation of cost.  We do not expect you to
develop new cost estimates.



Transmission and distribution projects are the piping needs of a water
system.  Projects for valves, other valves, and meters that are not part
of a transmission or distribution project listed in this table should be
recorded in the table on page 6.

Transmission and Distribution Inventory

On the table below, please provide an estimate of the total feet or
miles of pipe in your system, if possible.  Completion of this table is
not required, but it may be helpful to ensure all potential transmission
and distribution pipe projects are considered.  

Note:  The total feet or miles of pipe in your system is required
information if any pipe projects are submitted based solely on
survey-generated documentation (documentation codes 10 or 11).
______________	Total feet or miles of pipe in system (Circle or
underline feet or miles)    

												 

	Total Pipe in System

(Circle or underline feet or miles)

 	<=6 inch

8-12 inch

15-42 inch

>=48 inch	

	Plastic 	________	Feet or miles

Amount of PVC by pipe size	 ________	feet or miles	 ________	feet or
miles	 ________	feet or miles	 ________	feet or miles

________	% of total pipe

% of this category/size pipe currently in poor condition or beyond
useful life	 ________	%	 ________	%	 ________	%	 ________	%

Ductile Iron	________	Feet or miles

Amount of ductile iron by pipe size	 ________	feet or miles	 ________
feet or miles	 ________	feet or miles	 ________	feet or miles

________	% of total pipe

% of this category/size pipe currently in poor condition or beyond
useful life	 ________	%	 ________	%	 ________	%	 ________	%

Cast Iron	________	Feet or miles

Amount of cast iron by pipe size	 ________	feet or miles	 ________
feet or miles	 ________	feet or miles	 ________	feet or miles

________	% of total pipe

% of this category/size pipe currently in poor condition or beyond
useful life	 ________	%	 ________	%	 ________	%	 ________	%

Asbestos Cement	________	Feet or miles

Amount of asbestos cement by pipe size	 ________	feet or miles
 ________	feet or miles	 ________	feet or miles	 ________	feet or
miles

________	% of total pipe

% of this category/size pipe currently in poor condition or beyond
useful life	 ________	%	 ________	%	 ________	%	 ________	%

Other	________	Feet or miles

Amount of other by pipe size	 ________	feet or miles	 ________	feet or
miles	 ________	feet or miles	 ________	feet or miles

________	% of total pipe

% of other currently in poor 

condition or beyond useful life	 ________	%	 ________	%	 ________	%
 ________	%

Transmission and Distribution Projects 

Project

Number	Project Name	Type of Need

(List 1)	Reason for Need

(List 2)	New,

Replace, or

ReHab	Current

or

Future	Reg or Secondary Purpose

(List 3)

	Diameter of Pipe (Inches)	Length of

Pipe

(Feet)	Cost Estimate

(if available)	Date of Cost Estimate

(Month/Year)	Documen-

tation

(List 4)

Ex. 1	Cleaning and Lining Old Cast Iron Mains	M1	A1	H	C	4A	12	18,000	-	-
11

Ex 2	Replace Deteriorated Transmission Main	X2	A1	R	C	4A	24	20,000
$4,200,000	06/2008	1

2000

	2001

	2002

	2003

	2004

	2005

	2006

	2007

	

If a project is coded 2G for “climate readiness” from List 3, please
refer to page 7 for supplemental questions.

If you have more transmission or distribution projects check this box (
and continue on a supplemental sheet (included in this package or
downloadable at www.DWNeeds.com). Project numbers for transmission or
distribution projects are 2000-2999, and should be numbered in sequence.

EPA requires documentation of all projects provided.  Applicable types
of documentation are presented in List 4 of the Lists of Codes.

Use only existing documentation of cost.   We do not expect you to
develop new cost estimates.



Meters, Service Lines, Backflow Prevention Devices/Assemblies, Large
Diameter Valves, etc

Projects for meters, service lines, backflow prevention devices and
assemblies and other miscellaneous projects are recorded in this section
to accommodate entries of multiple identical items on one line in the
project table. Record only projects that are not a part of another
project (e.g., water main replacement projects will already include
valves, hydrants and other appurtenances).   EPA requires documentation
of all projects provided.  Applicable types of documentation are
presented in List 4 of the Lists of Codes. Use only existing
documentation of cost.  We do not expect you to develop new cost
estimates.

Number of Water Meters:

Total Number of Existing Backflow Prevention

Devices/Assemblies:

	Number of Backflow Prevention

Devices/Assemblies:

	Number of Backflow Prevention

Devices/Assemblies:

Total Number of Lead Service Lines:

Project

Number	Project Name	Type of Need

(List 1)	Reason for Need

(List 2)	New,

Replace, or

ReHab	Current

or

Future	Reg or Secondary Purpose

(List 3)	Size (Diameter in Inches)	Number Needed	Cost Estimate

(if available)	Date of Cost Estimate

(Month/Year)	Documen-

tation

(List 4)

Ex.1	Replace Lead Service Lines	M2	A6	R	C	1D	-	100	$100,000	05/2010	9,
11

3000

	3001

	3002

	3003

	3004

	Project

Number	Project Name	Type of Need

(List 1)	Reason for Need

(List 2)	New,

Replace, or

ReHab	Current

or

Future	Reg or Secondary Purpose

(List 3)

	Size (Diameter in Inches)	Number Needed	Cost Estimate

(if available)	Date of Cost Estimate

(Month/Year)	Documen-

tation

(List 4)

3005

	3006

	3006

	3008

	

If a project is coded 2G for “climate readiness” from List 3, please
refer to page 7 for supplemental questions.

If you have more of these types of projects check this box ( and
continue on a supplemental sheet (included in this package or
downloadable at www.DWNeeds.com). Project numbers for these types of
projects are 3000-3999, and should be numbered in sequence.

Climate Readiness

Supplemental Questions

If you used code 2G from List 3, in the “Regulation” column of the
survey, indicating that you have one or more projects that are related
to climate readiness, please answer the following questions. Only one
response is requested; do not provide a response for each project.

Projects that included a climate ready component [Project #(s)]: 
________________                                                        
   _                 

Which of the following secondary consequences of climate change have
contributed to your system’s need for climate readiness projects?
(check all that apply)

Source water quality (e.g., water quality degradation affecting
treatment processes, alternate sources, etc.)

Source water quantity (e.g., availability affected by snowmelt or
weather patterns, or hydraulic patterns)

Infrastructure Vulnerability (e.g., facility locations affected by sea
level rise, increased precipitation intensity)

Other (please explain)_______________________

Please describe the data you are relying on to determine climate change
consequences and implications.

Model developed from state-specific data.

Model developed from region-specific data.

Other (please describe)_______________________

Respondent Information

Please provide the following information in case we need to contact you
for clarification or additional explanation of any of your responses.

Contact Person (Person who completed this questionnaire):



Signature:  		

Name (please print):  		

Title:  		

Mailing Address:		

(Street Address) 

			

			

	

Telephone Number:  		

Fax Number:  		

E-mail Address:  		

Best Time to Reach You:  		



If you have any questions, contact your state coordinator 

(contact information can be found at   HYPERLINK
"http://www.dwneeds.com"  www.dwneeds.com )

or call the U.S. EPA toll-free Needs Survey Helpline at 1-888-766-3337. 

CLOSING: Thank you for your help. Did you remember to:

	Attach all additional project tables to the questionnaire? 

	Identify, by project number, available documentation for all needs and
costs reported above?

	Put the questionnaire and the documentation in the pre-paid,
pre-addressed Federal Express Pak provided and return this questionnaire
	and the documentation to the address below?  (See the pink enclosure
for further return instructions.)

 PAGE   

EPA Form 6100-02								  PAGE  1 									7/8/2011

EPA Form 6100-01																	7/8/2011

Source Projects are all projects related to collecting and pumping raw
water.  This includes wells, surface water intakes, springs, off-stream
raw water storage, pumps, and well houses.

Treatment Projects are all projects related to disinfection, filtration,
or other treatment processes for ground or surface water sources, or for
treatment applied in the distribution system.

Storage and Pumping Projects are related to finished or treated water
storage, and booster pump stations.

OMB No.: 

Approval Expires:  

Federal PWSID No.: ____________