Private Water Supplies Regulations 2016

Risk Assessment Questionnaire

Your name:
Contact telephone number:
1.  Address of water supply
2.  If known, please provide the grid reference of the location of the source.
3.  Type of supply (borehole, spring etc.)
4.  Please provide the names, addresses and contact telephone numbers of all properties served by the water supply.
Please also tell us what purposes the water is used for at each property, for example domestic use only, food preparation, holiday accommodation, restaurant, café, dairy farm, residential home.
Name / Address / Telephone number / Purpose of use
Please continue on a separate sheet if more space is required.
5.  Are there any written records or documents relating to the supply, for example instructions for equipment, records of maintenance, inspections undertaken? If yes please give details.
6.  Are there any latrines, septic tanks, animal enclosures or cess pits within 50m of the source? If yes, please give details.
7.  Are there any latrines, septic tanks, waste pipes, animal enclosures or cess pits in the vicinity of the distribution pipes? If yes, please give details.
8.  Is there a history of any fractures or faults in the distribution system that could allow contamination?
9.  Is there any way contamination could enter the distribution system via back-flow, for example animal drinking water troughs? If there is ponding of surface water or poor drainage, could water be pulled into the system during low pressure or changes in pressure for example back flow from hoses, taps or standpipes?
10. Are there any coal tar lined pipes? (Coal tar was used pre-1970s to line iron mains.)
11. Do any third parties have access to hydrants or other points in the distribution system?
12. Are there any valves in the network which are normally closed?
13. Are there any sections of pipework containing stagnant water?
14. Are there any copper or iron pipes? If yes, please give details.
15. Do all junctions in the supply network have back-flow protection?
16. Are there any known or potential cross-connections between different sources, greywater systems, sewage pipes or other waste pipes?
17. Have there been any complaints or reports of water quality problems, for example taste or odour?
18. Is there slurry spreading and/or storage of slurry or dung near the source?
19. Is there a risk of pesticide or chemical contamination of the source for example un-bunded heating oil storage tanks or use of sheep dipping?
20. Are chemical fertilisers used in the catchment?
21. Is there a history of mining in the catchment?
22. Does the local geology suggest the presence of boron, arsenic, lead, fluoride, uranium, nickel or radon in the source?
23. Is the source likely to be affected by contaminated land in the catchment, including land fill?
24. Is the source sufficient i.e. has it ever run dry or been over-abstracted?
25. Is the source protected against vandalism? Please give details.
26. Is there a noticeable change in the appearance of the water from time to time?
27. Is there waste-water discharging chemical or biological matter into the source?
28. Are there unbunded stores of farm waste or silage in the catchment?
29. Are there any fish farms upstream of the intake?
30. Is there any construction or development activity upstream of the intake?
31. Is there any quarrying in the area?
32. Is the source water used for recreational activities, boating for example?
33. Is the source water subject to seasonal algal blooms?
34. Is there a risk of oil entering the supply? For example generators, household heating oil, farm fuel, generators or traffic accidents.
35. Is the water treated? If yes please give details of the type of treatment for example UV disinfection, filters, pH balancing, manganese removal. Please tell us if the whole supply is treated, or if it is treated at individual properties on the supply.
36. Are storage tanks used to store water prior to it being treated or to store water where there is no treatment?
37. Are storage tanks used to store water after it is treated?
38. At any of the properties on the supply, is drinking water (kitchen tap) supplied via a loft tank? If yes, please give details of which properties have loft tanks.
39. Please provide us with a site plan showing the location of the source, any tanks, distribution pipework, valves and the location of consumer premises.

Please return this questionnaire to Public Protection, Cornwall Council, Dolcoath Avenue, Camborne, TR14 8SX

If you have any queries or wish to discuss the questionnaire, please contact us on 0300 1234 212.