Public Drinking Water Program Forms

Public Drinking Water Program
Public Water Supply Operation
Anne Lynam, Environmental Specialist Senior
Telephone: 515-725-0280, anne.lynam@dnr.iowa.gov

 

IDNR Public Water Supply Report forms:
Listed below are the monthly operation report templates, sampling plan templates, and other forms and guidance documents used by public water supplies to report information to IDNR's Water Supply Operation Section and Environmental Field Offices.  Several of the forms and templates are based upon the population served in the system and the source water type: groundwater (GW), surface water (SW), or groundwater under the direct influence of surface water (also called influenced groundwater, or IGW). 

Monthly Operation Reports (MORs): Form # *.xls *.pdf
Large (>10,000 people served) surface water or influenced groundwater system monthly operation report form
Note: The Excel workbook contains macros.
542-8027 Large SW/IGW monthly operation reporting form, 542-8027 in xls format Large SW/IGW monthly operation reporting form, 542-8027 in pdf format
Small (<10,000 people served) surface water or influenced groundwater system monthly operation report form
Note: The Excel workbook contains macros.
542-8032 Small SW/IGW monthly operation report form, 542-8032 in xls format Small SW/IGW monthly operation report form, 542-8032 in pdf format
Consecutive surface water or influenced groundwater system monthly operation report form 542-8110 SW/IGW consecutive monthly operation report form, 542-8110 in xls format SW/IGW consecutive monthly operation report form, 542-8110 in pdf format
Membrane filtration monthly operation report form for SW/IGW systems  542-8109  SW/IGW membrane filtration monthly operation report form, 542-8109 in xls format  SW/IGW membrane filtration monthly operation report form, 542-8109 in pdf format
Groundwater system monthly operation report form 542-3104 GW monthly operation report form, 542-3104 in xls format GW monthly operation report form, 542-3104 in pdf format
Groundwater system monthly operation report form where system has been approved for 4-log virus inactivation under the Groundwater Rule  542-0038 

Groundwater Monthly Operation Report for 4-log, 5420038 in xls format

Groundwater Monthly Operation Report for 4-log, 5420038 in pdf format

Consecutive groundwater system monthly operation report form 542-8099 GW consecutive monthly operation report form, 542-8099 in xls format GW consecutive monthly operation report form, 542-8099 in pdf format

Iowa Online Turbidimeter Calibration and Verification Guidance Document

Lead and Copper Sampling Plan:
The Lead and Copper Rule sampling plan template is available in fillable .pdf and .doc formats. The plan is also available in a modifiable MS-Word format, upon request from the Water Supply Operations Section or the Field Office. 

Lead and Copper Sampling Plan (542-0357)
Lead and Copper Sampling Plan (542-0357)

Stage 2 DBPR Sampling Plans:
Listed below are templates for Stage 2 Disinfectant/Disinfection Byproducts Rule sampling plans, by source water type and population. The templates are available in fillable .pdf and .doc formats.

Stage 2 DBPR groundwater system serving 25-9,999 people monitoring plan (542-0458)
Stage 2 DBPR groundwater system serving 25-9,999 people monitoring plan (542-0458)

Stage 2 DBPR groundwater system serving 10,000-99,999 people monitoring plan (542-0459)
Stage 2 DBPR groundwater system serving 10,000-99,999 people monitoring plan (542-0459)

Stage 2 DBPR surface water or IGW system serving 25-499 people monitoring plan (542-0460)
Stage 2 DBPR surface water or IGW system serving 25-499 people monitoring plan (542-0460)

Stage 2 DBPR surface water or IGW system serving 500-3,300 people monitoring plan (542-0461)
Stage 2 DBPR surface water or IGW system serving 500-3,300 people monitoring plan (542-0461)

Stage 2 DBPR surface water or IGW system serving 3,301-9,999 people monitoring plan (542-0462)
Stage 2 DBPR surface water or IGW system serving 3,301-9,999 people monitoring plan (542-0462)

Stage 2 DBPR surface water or IGW system serving 10,000-49,999 people monitoring plan (542-0463)
Stage 2 DBPR surface water or IGW system serving 10,000-49,999 people monitoring plan (542-0463)

Stage 2 DBPR surface water or IGW system serving 50,000-249,999 people monitoring plan (542-0464)
Stage 2 DBPR surface water or IGW system serving 50,000-249,999 people monitoring plan (542-0464)

Stage 2 DBPR - Change of Sampling Site form (542-0465)
Stage 2 DBPR - Change of Sampling Site form (542-0465)

Stage 2 DBPR - Operational Evaluation Level Report Form (542-0554)
Stage 2 DBPR - Operational Evaluation Level Report Form (542-0554)

Revised Total Coliform Bacteria Rule and Groundwater Rule Sampling Plans:
Listed below are templates for revised total coliform bacteria sampling plans, which also include the groundwater rule sampling plan requirements when indicated. The templates are available in fillable .pdf and .doc formats. The plans are also available in a modifiable MS-Word format, upon request from the Water Supply Operations Section or the Field Office.

RTCR-GWR Sampling Plan for Groundwater PWS collecting one bacteria sample per quarter (542-0724)
RTCR-GWR Sampling Plan for Groundwater PWS collecting one bacteria sample per quarter (542-0724)

RTCR-GWR Sampling Plan for Groundwater PWS collecting one bacteria sample per month (542-0467)
RTCR-GWR Sampling Plan for Groundwater PWS collecting one bacteria sample per month (542-0467)

RTCR-GWR Sampling Plan for Groundwater PWS collecting 2 or more bacteria samples per month (542-0457)
RTCR-GWR Sampling Plan for Groundwater PWS collecting 2 or more bacteria samples per month (542-0457)

RTCR Sampling Plan for SW/IGW PWS collecting 2 or more bacteria samples per month (542-0896)
RTCR Sampling Plan for SW/IGW PWS collecting 2 or more bacteria samples per month (542-0896)



Other Forms and Guidance: *.doc *.pdf
Groundwater Rule 4-Log Virus Inactivation Application 4-log application, in doc format 4-log application, in pdf format 
IDNR Groundwater Rule Quick Reference Guide    IDNR Ground water rule quick reference guide, in pdf format 
Lead Consumer Notice for Community Systems lead consumer notice for community, in doc format lead consumer notice for community, in pdf format 
Lead Consumer Notice for Nontransient Noncommunity Systems lead consumer notice for NTNC, in doc format lead consumer notice for NTNC, in pdf format
Lead and Copper Consumer Notice for Community Systems lead and copper consumer notice for community, in doc format lead and copper consumer notice for community, in pdf format
Lead and Copper Consumer Notice for Nontransient Noncommunity Systems lead and copper consumer notice for NTNC, in doc format lead and copper consumer notice for NTNC, in pdf format
Lead and Copper 90th Percentile Calculation Form lead and copper 90th form, in doc format lead and copper 90th form, in pdf format
Water well abandonment reporting form: Abandoned Water Well Plugging Record, Form# 542-1226 well plugging form, 542-1226 in doc format well plugging form, 542-1226 in pdf format
Operator Certification Compliance Plan, form 542-3120
Operator Certification Compliance Plan, form 542-3120