States & Territories

Appendix C
Small Community
Form Wireframes

www.epa.gov/cwns/small-community-form-MN

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Clean Watersheds Needs Survey
Small Community Form

The state environmental department requests your assistance to accurately account for state's needs by
completing this form. This information will help to better represent the capital needs for wastewater
improvements of smaller state communities. Only needs as of January 1, 2022 (i.e., portions of projects not
funded as of January 1, 2022) are eligible and should be listed. They can include estimates for new
infrastructure, sustaining current infrastructure, and/or meeting future growth needs (through December 31,
2042).
For any questions, please contact State Coordinators Name at Email Address.
Please answer these questions before beginning the survey:
1. Is your facility federally owned or located on tribal or military land?
1. If No: Show question 2.
2. If Yes: Display “Your Facility’s needs are not eligible for the CWNS. Thank you for your
time.” END
2. Does your Facility have water quality related capital improvement needs?
• If No: Display: “Please provide or update your facility’s information.” Display Survey
sections Facility Info only. END
• If Yes: Show question 3.
3. Are the costs of the capital improvement needs documented (such as in a capital
improvements plan or engineering report)?
• If No: Show question 4.
• If Yes: Display Survey sections Facility Info, Solutions and Costs, and Local Official PE
Certification. END
4. Do you want to use EPA cost estimation tools to estimate costs?
• If No: Show question 5.
• If Yes: Display Survey sections Facility Info, Solutions and Costs, and Cost Estimation
Tools. END
5. Are you submitting costs developed for the CWNS and have a Professional Engineer (PE) to
certify the costs?
• If No: “After completing the form, a state PE may certify your costs.” Display Survey
sections Facility Info, Solutions and Cost. END
Alt No (if State user doesn’t have State PE): “These costs cannot be certified and
included in the CWNS. Please consider using cost estimation tools or obtaining a PE
signature.” END
• If Yes: Display Survey sections Facility Info, Solutions and Costs, and Local PE
Certification. END

Yes

Yes

Yes

Yes

Yes

Facility Information
Needs and Costs
Cost Estimation Tools
Local Official Certification
Local PE Certification
Submit

www.epa.gov/cwns/small-community-form-MN

Clean Watersheds Needs Survey
Small Community Form

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*

Facility Information

Indicates required field.

Infrastructure Type:

DEP Generated

* Facility Name:
* Authority Name:

Free Text

* Facility Address:
Address 2:

Free Text

Free Text
P.O. Box is not allowed. If a facility
doesn’t have an address, please
indicate physical location with
description instead (e.g., 5 miles
south down Rt. 9 from City Hall).

Free Text
Free Text

City:
Dropdown

* State:
* County:

Free Text
xxxxx-xxxx

Zip Code:
* Owner:

Private

Public

Contact Name:

Free Text

Role/Title:

Free Text

Phone Number:

xxx-xxx-xxxx

Fax Number:

Ext:

xxx-xxx-xxxx

Email:

Free Text

* Facility Types and Planned Changes

Facility Type

Planned Changes

Facility Type Dropdown

Change Type Dropdown (filtered based on
facility type)

Treatment Plant

Expansion

Treatment Plant

Process Improvement

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Clean Watersheds Needs Survey
Small Community Form
Facility Information, continued

* Discharge Type

* % Of Discharge

Wastewater discharge type dropdown.

Please make sure % of discharge adds to 100%.
Please name the facility(ies) this facility
discharges to, along with location(s) and
NPDES permit number(s) if known:

Free text.

Effluent
* Current Effluent Treatment Level:

Secondary

* Is there Disinfection (e.g., chlorine, UV) currently in place?
* Future Effluent Treatment Level:

Yes

No

Yes

No

Secondary

* Will there be Disinfection (e.g., chlorine, UV) in the future?

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Small Community Form

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Facility Information, continued
Population Information for Infrastructure Type: Wastewater

Resident Population
Projected Design
Population in 204X

202X

Population Receiving Collection

Non-Resident Population
Projected Design
Population in 204X

202X

* 10000

* 8000

Population Information for Infrastructure Type: Decentralized Wastewater

Resident Population
Projected Design
Population in
204X

202X
Population
per Unit

Numbe
r of
Units

Non-Resident Population

Tota
l

Number
of Units

Total

Projected Design
Population in
204X

202X
Population
per Unit

Number
of Units

Total

Number
of Units

Cluster Systems

2.31

25

58

45

104

2.31

25

45

Onsite Wastewater Treatment
Systems

2.31

25

58

45

104

2.31

25

45

Total Receiving Treatment

116

Total

208

Flow Information for Infrastructure Type: Wastewater

Total Flow

Actual Average
Flow (MGD)

Current Design
Flow (MGD)

Future Design Flow
(MGD)

1.25

31

4

83

2,067

200

Wet Weather Flow (Peak)

Flow to Population Ratio Information
Flow to Population Ratio (GPCD)

* Select a reason for out-of-range
Flow to Population Ratio (GPCD)
Please explain:
Free text.

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Clean Watersheds Needs Survey
Small Community Form

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Needs and Costs
CWNS Need Categories

Need Description

Need Amount in
Document ($)

Do you have a
document describing
these costs or would
you like to model them
(if available)?

Free Text

Numbers (comma
separated)

Dropdown: Yes, No, I
would like to model
costs

-Secondary Treatment
(including sludge
handling/disposal)
Advanced Wastewater
Treatment
Infiltration/Inflow Correction
Sewer Replacement/
Rehabilitation
New Collector Sewers
New Interceptor Sewers
CSO Correction
Stormwater Management
Programs
Cluster Systems
(Decentralized)
Onsite Wastewater Treatment
Systems (Decentralized)
Recycled Water Distribution
Nonpoint Source Pollution
Control
If you have documents describing these costs, please send them to your state CWNS coordinator: state coordinator email.

* Water quality reason(s) for the planned projects:

 The project(s) is required to maintain compliance with an NPDES permit.
 The project(s) is to obtain compliance with a new permit requirement.
 The project(s) is to increase capacity or improve treatment in advance of anticipated new permit
requirements.
 This facility is not regulated by an NPDES permit; however, the project(s) will prevent unregulated
water quality or human health impacts.
 The project(s) is to achieve or maintain compliance with a total maximum daily load (TMDL).

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Small Community Form

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Cost Estimation Tools
Wastewater: Treatment Plant
Practice Type

Change Type

Construction Type

Future Design
Flow (MGD)

Lagoon

Treatment Upgrade
Replace

3.05

Aerated Lagoon

Treatment Upgrade
Rehabilitation

10

Secondary Mechanical
Advanced
Disinfection Only

Treatment Upgrade

Chlorine

Treatment Upgrade

Chlorine

13

Ultraviolet (UV)

Wastewater: Collection
Category

Sewer Type

Infiltration/Inflow
Correction

Combined

Change

Length of Pipe (ft)

Rehabilitation

Number of
Pump Stations

Pump Station
Capacity
(MGD)

3

5

150,000

Major Sewer System
Rehabilitation
New Collector Sewers
and Appurtenances
New Interceptors and
Appurtenances

Interceptor

New

Interceptor

New

Separate

Replace

Pump Stations

Expansion

15,000

Decentralized
This Cost Estimation Tool estimates costs for new or replaced decentralized onsite systems based on the
number of homes. This model is not for rehabilitation of decentralized systems.
Number of Homes Served
If number of homes served/systems is not known, use the inputs below

Population Served
Population per Household

(default value that can be
altered)

www.epa.gov/cwns/small-community-form-MN

Clean Watersheds Needs Survey
Small Community Form

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Cost Estimation Tools
CSO
This Cost Estimation Tool estimates costs for new or replaced combined sewer overflow systems based on
the total capacity in million gallons. This model is not for rehabilitation or expansion of CSO systems.
Capacity

million gallons

Stormwater
Practice Type

Construction
Type

Quantity

Area
(ft2)

Volume
(ft3)

Drainage
Area
(Acres)

Percent
Imperviousness
(%)

Dry Pond

New
New

5

15,000

200,000

2.5

55

Wet Pond

Redevelopment
Redevelopment

3

10,000

50,000

2

75

2

13

13

Underground
Detention or
Retention
Vegetated Swale
Above Ground
Storage Tank
Porous Pavement
Green Roof
Constructed
Wetland
Bioretention
Buffer Strip
Infiltration
Trench

New
New
Redevelopment

1

60

www.epa.gov/cwns/small-community-form-MN

Clean Watersheds Needs Survey
Small Community Form

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Local Official Certification
As the local official representing this community, I agree that the facility information
described herein is accurate for this community.
I do not have cost documentation, but the needs described herein are accurate for
this community.
Typing your name here serves as
a digital signature.

Name:
Title:
Date:

You indicated that you need a PE signature. Please enter PE information below so they can review and
sign this form. (Display if question 5 = Yes).
Name:
Email:

Local PE Certification
To be completed by a Local Professional Engineer. Signature certifies that the costs included in
this Small Community Form are reasonable.
Name:

Typing your name here serves as
a digital signature.

Title:
PE Number:
Date:

State PE Certification
To be completed by a State Professional Engineer. Signature certifies that the costs included in
this Small Community Form are reasonable.
Name:
Title:

Typing your name here serves as
a digital signature.

PE Number:
Date:

Submit