Will actions have the potential to impact, or be impacted by seasonal variations in precipitation? Will actions have the potential to impact: Drinking water supplies of humans, animals, or plants? Water supply sources for irrigation? For example, via the; extraction of surface water. run-off of pesticides, fertilizers, or toxic chemicals. discharge of domestic or industrial sewage. increased volume of storm water run-off and/or potential for discharge of potentially contaminated (including suspended solids) storm water. discharge of livestock wastes such as manure or blood into surface water. interference with the current drainage systems or conditions. increased risk of flooding. alteration of downstream flow. Will actions result in increased ground water extraction? For example, by pumps or wells. If yes: What are the volumes? What are the permit requirements?
Are there known geological hazards, e.g., faults, landslides, or unstable soil structure, which could affect the activity? If yes: How will the project ensure the integrity of any structural components and associated equipment? Will the site require grading, trenching, or excavation? Will actions generate borrow pits? If yes: How will these be managed during implementation and closure? Will actions impact or be impacted by the presence of prime or unique farmland? Will actions result in any land clearing?
(e.g., by impeding access to a place of worship)? Are there unique ethnic or traditional cultures or values present at or associated with the site? If yes: What is the applicable preservation plan? Will any villages or towns be directly affected by the project? Are any such settlements located within a 5-km radius of the project site/sites? If yes: What is the applicable preservation plan? Are any dispersed rural households located on the site or adjacent to it (within a 1-km radius)? If yes: What is the applicable preservation plan? Will pastoralists, indigenous peoples, or local people be affected? For example, via the action, will their lands no longer be usable in traditional, customary ways? Will their land or natural resource rights (including customary or temporary tenure systems) be infringed upon in any way? If yes: What is the applicable preservation plan?
How do impacts vary between gender? Will the activity disproportionately impact one gender versus the other? What are the potential impacts on existing land tenure arrangements (whether formal or informal)? Could the action worsen existing land tenure conflicts or violence in the area? If yes: What is the applicable prevention plan? Will actions, e.g., construction, refurbishment, demolition, or blasting, result in increased noise or light pollution that could adversely affect the natural or human environment?
V – (The following forms are filled out for a generic water supply construction project, but the forms can be used for any project type.) Project: [Project Name] Date: ORDER NAME DESCRIPTION Activity 1 Illustrative Example: Site Preparation and Construction Mobilization; site preparation/clearing; pipeline, intake, pump, and treatment station construction (trenching/directional drilling in uplands, wetlands, streams); building access/service roads Activity 2 Activity 3 Activity 4 INPUTS OUTPUTS Action 1 – Illustrative Example Site Preparation and Construction Energy: Electricity fuel Welding/cutting gases Air emissions: Dust Vehicle/generator exhaust Welding fumes Water: Source water Equipment wash-down water (ground) Drilling mud make-up water (ground) Discharges to water: Contaminated stormwater and wash water (silt, oils, etc.) Fill material Water from de-watering Materials: Pipe Pipe fittings Gravel Sand Concrete wastes: Used or excess materials/supplies/consumables (see inputs) Excavated soil Used drilling mud Supplies/consumables: Welding rod Lumber (forms) Gloves, rags Construction stakes Silt straw bales Pallets Spills and hazards: Potential fuels and chemical spills (see inputs) Potential occupational hazard from dam building, equipment movement, handling pipe, trenching, drilling, welding Disturbing buried contaminants, e.g., old asbestos pipes, contaminated soils
Human trafficking, sexually transmitted infections, other social impacts from temporary construction camps Chemicals: Curing compounds Form oils Aerosols Concrete additives Paints Environmental alteration/impairment: Reduced downstream flow and aquatic ecology alteration Wetland degradation Vegetation removal Loss of endangered species Habitat alteration and wildlife impacts from clearing of staging areas and construction of access roads Drainage impairment Prehistoric/historic site alteration Soil/geologic alteration Other inputs outputs: Traffic congestion Noise Light Action 2 – Energy: Air emissions: Water: Discharges to water: Materials: Solid wastes: Supplies/consumables: Spills and hazards: Chemicals: Environmental alteration/impairment: Other inputs Other outputs: Action 3 – Energy: Air emissions: Water: Discharges to water: Materials: Solid wastes: Supplies/consumables: Spills and hazards: