Form 6100-02 2015 Drinking Water Infrastructure Needs Survey and Asse

2015 Drinking Water Infrastructure
Needs Survey And Assessment
U.S. Environmental Protection Agency

OMB No.:
Approval Expires:
Federal PWSID No.:

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:
Street Address:
City, State, and Zip:
Population Served (if wholesaler,
include consecutive population
as appropriate):
Number of Connections (not
including consecutive systems):
Total System Design Capacity (in
MGD):
Total Length of Pipe in System
(in Feet):
Source Water Type (Ground, Surface/GWUDI, etc.):

Check All That Apply:

Check All That Apply:
Ownership Type:

Ground

Surface/GWUDI

Purchased Ground

Purchased Surface/GWUDI

Public

Investor-Owned or

Federal Government

Private Non-Profit

Public reporting burden for this collection of information is estimated to average 5.53 hours per response. This estimate includes time for review ing the instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and review ing 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 w ays to comply w ith any previously applicable instructions; search data sources; complete and review the
collection of information; and transmit or otherw ise 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. It is our experience that this information is rarely requested.

EPA Form 6100-02

Project Table
Project
Number

Project Name

EPA Form 6100-01

Type of
Need

Reason
for Need

N,E,R,H

C or F

Regulation

Design
Capacity

Diameter

Federal PWSID No.:
Length

Number
Needed

Cost
Estimate

Cost
Date

0
Documentation

Remove
M odify or
Validate

Comment
Codes

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.
How ever, completion of this table is not required.
▪ Source Projects are all projects related to collecting and pumping raw w ater. This includes w ells, surface w ater intakes, springs, off-stream raw
w ater storage, and pumps.
▪ Treatm ent Projects are all projects related to disinfection, filtration, or other treatment processes for ground or surface w ater sources, or for
treatment applied in the distribution system.
▪ Storage and Pum ping Projects are related to finished or treated w ater storage, and booster pump stations.

Inventory

Source Water
Needing Rehabilitation

Needing Replacement

Total Number and Capacity of Existing Wells (pumps included) or Springs:
Wells or Springs:

Wells (pumps included) or Springs:

New Infrastructure Needs
Does your system have additional source w ater capacity
needs to meet the needs of current users?

Yes
No
Existing Surface Water Intakes (excluding
pumps):
If yes, how many additional sources are necessary?

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

Total Number and Capacity of Existing Existing Groundw ater Pumps (if w ells Existing Groundw ater Pumps (if w ells not
Pumps (excluding booster pump
not listed):
listed):
stations):
Existing Raw Surface Water Pumps:

Existing Raw Surface Water Pumps:

Treatment
Inventory

Needing Replacem ent

Needing Expansion/Upgrading or
Rehabilitation

For the sources identified above, enter the number of locations w here the follow ing treatment is applied:
Disinfection (including booster
Disinfection:
Disinfection:
disinfection):
Filtration:

Filtration:

Filtration:

Chemical removal or addition:

Chemical treatment:

Chemical treatment:

New Infrastructure Needs
Does your system have additional treatment needs for
provisions of additional public health protection or for
aesthetic concerns?

Yes

No

If yes, how much additional treatment is necessary?

Storage and Pump Stations
Inventory
Needing Replacem ent
Needing Rehabilitation
Total Number and Capacity of Existing Number of Existing Elevated or Ground- Number of Existing Elevated or GroundStorage Tanks:
Level Storage Tanks:
Level Storage Tanks:

Total Number and Capacity of Existing Number of Existing Booster Pump
Booster Pump Stations:
Stations:

EPA Form 6100-02

Number of Existing Booster Pump
Stations:

New Infrastructure Needs
Does your system have additional storage capacity and/or
booster pumping needs to meet the needs of current
users?
Yes
No
If yes, how much additional finished w ater storage or
booster pumping capacity is necessary?

Transmission and Distribution Inventory
Transm ission and distribution projects are the piping needs of a w ater system. Projects for valves, backflow prevention devices and assem blies, and m eters that
are not part of a transmission or distribution project listed in this table should be recorded in the table under the tab titled "Inventory Table 3".
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.

Total Pipe
feet
miles in System
(Check feet or miles)

Note: The total feet or miles or 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 Pipe in System
(Check feet or miles)

<=6 inch
feet
miles

Plastic
% of total
pipe

Ductile
Iron

feet
miles
% of total
pipe
feet
miles

Cast Iron
% of total
pipe

Asbestos
Cement

feet
miles
% of total
pipe

Other

feet
miles
% of total
pipe

EPA Form 6100-02

8-12 inch
feet
miles

Amount of PVC by pipe size
% of this category/size pipe
currently in poor condition or
beyond useful life

%

Amount of ductile iron by pipe
size
% of this category/size pipe
currently in poor condition or
beyond useful life

%

% of other currently in poor
condition or beyond useful life

%

feet
miles

%
feet
miles

%
feet
miles

%

%

%

%

feet
miles

feet
miles

feet
miles

feet
miles

%

%

%

feet
miles

feet
miles

feet
miles

feet
miles

Amount of other by pipe size

%

%

%

feet
miles

feet
miles

feet
miles

Amount of asbestos cement by
pipe size
% of this category/size pipe
currently in poor condition or
beyond useful life

%

%

>=48 inch

feet
miles

feet
miles

Amount of cast iron by pipe size
% of this category/size pipe
currently in poor condition or
beyond useful life

15-42 inch

feet
miles

%
feet
miles

%

feet
miles
%

Meters, Service Lines, Backflow Prevention Devices/Assemblies, Valves, etc.
Projects for meters, service lines, backflow prevention devices and assemblies, valves, 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 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.
To ensure all potential projects are considered, it may be helpful to complete some or all of this inventory table. However, completion of this table is not required.
Inventory
Total Number of Existing Water
Meters:

Needing Replacement
Number of Water Meters:

New Infrastructure Needs
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 Valves:

Number of Valves:

Number of Valves:

Total Number of Lead Service Lines:

EPA Form 6100-02

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:

Telephone Number:

Name (please print):

Fax Number:

Title:

E-mail Address:

Mailing Address:

Best Time to Reach You:

(Street Address)

If you have any questions, contact your state coordinator.

CLOSING: Thank you for your help. Did you remember to?
Identify, by project number, available documentation for all needs and costs reported?
Email the questionnaire and email or mail the documentation to your state?

EPA Form 6100-02

Summary of Survey-Generated and Independent Documentation for Each Project
Project
Number

Project Name

EPA Form 6100-02

Documentation
Code(s)

State/System Survey-Generated Statement

Federal PWSID No.:

Independent
Document Name

0
Independent
Documentation
Page Number(s)