Water Supply Wells - Premier of Ontario



Example of a Written Record for Reporting Free Chlorine Residual TestsIs this a: (circle one option)New wellAlteration to existing wellPump installationWell tag number: [enter info]Well purchaser name: [enter info]Well purchaser address: [enter info]Well purchaser telephone number: [enter info]Location of well: [enter info]Date of structural stage of well completed/pump installed: (DD/MM/YYYY)Initial date and time of dosing well: (DD/MM/YYYY) Time: [enter time] AM or PM (circle)Date and time for testing:Free chlorine residual: (DD/MM/YYYY) Time: [enter time] AM or PM (circle)Concentration of free chlorine residual and time elapse after dosing:Between 12 to 24 hours after dosing well: [value] mg/L Time: [info] HoursDid test have to be repeated? Yes or No (circle)If yes, continue with next questionsIf no, go to Lines 21 and 22Date of pumping out chlorinated well water: (DD/MM/YYYY)Concentration of free chlorine residual after pumping well-water out of well: [value] mg/LDate and time of re-dosing well: (DD/MM/YYYY) Time: [enter time] AM or PM (circle)Concentration of free chlorine residual and time elapse after dosingBetween 12 to 24 hours after re-dosing the well: [value] mg/L [info] HoursDid test have to be repeated again? Yes or No (circle)If yes, continue with next questionsIf no, go to lines 21 and 22Date of pumping out chlorinated well-water: (DD/MM/YYYY)Concentration of free chlorine residual after pumping well-water out of well: [value] mg/LDate and time of re-dosing well: (DD/MM/YYYY) Time: [info] AM or PM (circle)Concentration of free chlorine residual and time elapse after dosingBetween 12 to 24 hours after re-dosing the well: [value] mg/L [info] HoursConcentration of free chlorine residual after pumping well-water out of well: [value] mg/LType of test used to measure free chlorine residual concentration: (circle one option)Test stripsColourimeterOther (specify)Name of person constructing the well/ installing a pump: (Please print first and last name)Well technician license number: [enter info]Well contractor license number: [enter info]Signature of person constructing the well/ installing a pumpDate: (DD/MM/YYY) ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download