J.6_StubCreekCenterWaterSystemSS_08-27-2018.pdf

Sanitary Survey – Stub Creek Work Center August 27, 2018

W- 1

Parts I, II, and III

OFFICE, FIELD AND REPORT DATA FOR

SANITARY/CONDITION SURVEY

of a

DRINKING WATER SYSTEM

Water System Name : Stub Creek Work Center

System Classification (Public, Non-Public) : Transient, Non-Community (TNC)

Forest : Arapaho and Roosevelt National Forest and Pawnee National Grassland

District : Canyon Lakes Ranger District

Year of Survey (YYYY) 2018

Real Property Number 0400

Forest Service, or State or EPA I.D. Number: 335219

W- 2

PART I

OFFICE DATA FOR SANITARY/CONDITION SURVEY

(DRINKING WATER)

Forest : Arapaho and Roosevelt National Forest and Pawnee National Grassland

District : Canyon Lakes Ranger District

Forest Service, or State or EPA I.D. Number: 335219

Date Compiled (MM,DD,YY) : August 27, 2018

Data Compiled By : /s/ Chris Ida

INDEX

PART I

ITEM NO. PAGE

PART I - OFFICE DATA

Cover W-1 Index W-2 IA. Design and Construction Information W-3 IB. Water System Classification W-3 IC. Water Analysis Records W-4 ID. Baseline Testing W-5 IE. Potential Source of Contaminants W-7 IF. Certified Operator W-7 IG. Use Records

7. Water Meter Reading Worksheet

8. Electrical Meter Reading Worksheet

W-7 W-8 W-9

IH. Records

1. Operation and Maintenance

2. Sanitary/Condition Survey

3. Water Rights

4. Watershed

5. Record Retention

W-10 W-10 W-10 W-10 W-10 W-11

II. Annual Operation and Maintenance Worksheet - Drinking Water W-11

W- 3

PART I - OFFICE DATA

A. DESIGN AND CONSTRUCTION RECORDS

1. Engineering Report: YES (Y/N) When 1999

2. Design criteria: YES (Y/N)

3. Construction drawings and specifications: YES (Y/N)

4. "As-built" drawings: (If YES, provide copy) YES (Y/N)

5. Sketch: (If YES, provide copy) NO (Y/N)

6. Is there a site plan: (If YES, provide copy) YES (Y/N)

7. Final construction report: YES (Y/N)

8. Type of site served: ADMINISTRATIVE (Special Use, Admin, Recreation, Other)

9. When constructed: 1972

10. Modifications Since Construction: YES (Y/N) Describe:

a. LEAK DETECTION WITH PHONE

DIALER ADDED

b.

Remarks:

B. WATER SYSTEM CLASSIFICATION

1.

2.

3.

Maximum number of persons using the system per day:

How many days per year?

Use Period Signature & Date of Whom made Determination: CHRIS N. IDA 03/22/2019 INFRA

153 DAYS

JUNE 1 TO

OCTOBER 31

4. Drinking water is what classification TNC

5. Is the class in No. 4, the same as what the EPA or State have on file? YES (Y/N)

6. Class Definitions

a. Public: (At least 25 people, at least 60 days per year, or 15 service connections)

1. Community (C) serves a residential population on a year-round basis.

2. Transient Non-Community (TNC)-Does not serve a residential population (campgrounds)

3. Non-Transient, Non-Community (NTNC)-Does not serve a residential population but does serve at least 25 of the same people over 6 months per year on a regular basis. (School, Office)

b. Non-Public (NP) (serves less than 25 people, 60 days/per year or 15 service connections

1. Non-Public, Transient (NPT)- Does not serve more than 25 persons less than 180 days.

(small picnic and campgrounds).

2. Non-Public, Non-Transient (NPNT) - serves less than 25 year-round residents or serving less than 25 persons more than 180 days per year. (smaller workstations and work centers)

W- 4

7. Water meter readings available: NO (Y/N)

8. Electrical meter readings available: NO (Y/N) (If YES, provide copy)

9. Water meter reading worksheet (See Page WI-8) NO

10. Electrical meter reading worksheet (See Page WI-9) NO

C. WATER ANALYSIS RECORDS

1. Classification - Public, Non-Transient, Non-Community, Ground Water

Testing

1. Bacteriological:

A. Seasonal System-must monitor for total coliform 10 days prior to opening for season:

YES (Y/N)

B. Monthly routine sample: YES (Y/N) C. Comments: FOREST SERVICE PERFORMS BACTERLOGICAL

WATER TESTING

2. Turbidity: NOT REQUIRED

3. Baseline Testing: NOT REQUIRED

4. Inorganics (IOCs): Generally not required except for nitrates.

A. Nitrate: Required every year B. Nitrate: Required once (before chlorination):

NO (Y/N)

NO (Y/N)

5. Palatability and Esthetic Acceptability A. Alkalinity: NO (Y/N) B. Hardness: NO (Y/N) C. PH (on site)** NO (Y/N) D. Iron** NO (Y/N) E. Manganese** NO (Y/N) F. Sulfide: NO (Y/N) **Requred under baseline testing

6. Organics:

A. (Herbs and Pests) SOC's (Required for systems specified by Health

Department)

NOT REQUIRED

B. THM's (Not Required) NOT REQUIRED C. VOC's (Required) NOT REQUIRED

7. Radioactivity: Not Required (Community Systems Only) NOT REQUIRED

8. Lead and Copper: NO (Y/N)

9. Disinfection: YES (Y/N)

10. Has a Microscopic Particulate Analysis (MPA) been completed on this source:

If yes, when: 8/04/2009

YES (Y/N)

11. Remarks: NEED TO KEEP RECORDS OF BACTERIOLOGICAL AND

NITRATE TEST RESULTS

W- 5

2. Classification - Public, or Non-Public (Transient) Non-Community, Ground, or Surface Water

Testing

1. Bacteriological:

A. Seasonal System-must monitor for total coliform 10 days prior to opening for season:

YES (Y/N)

B. Monthly routine sample (USFS) YES (Y/N) C. Comments: NEED TO KEEP RECORDS OF BACTERIOLOGICAL

2. Turbidity: (Not Required for Ground Water, Required for Surface): NOT REQUIRED

3. Baseline Testing: (See page W-5) SEE BELOW

4. Inorganics (IOCs): (Generally not required except ) A. Nitrate: Required every year: NO (Y/N)

(EVERY 3

YEARS)

B. Nitrate: Required once (before chlorination): NO (Y/N)

(REQUIRED

ONCE BEFORE

CHLORINATION)

5. Palatability and Esthetic Acceptability (USFS) A. Alkalinity NO (Y/N) B. Hardness: NO (Y/N) C. PH (on site)** NO (Y/N) D. Iron** NO (Y/N) E. Manganese** NO (Y/N) F. Sulfide: NO (Y/N) **Required under baseline testing

6. Organics:

A. Herbs and Pests (Not Required) NOT REQUIRED B. THM's (Not Required) NOT REQUIRED C. VOC's (Not Required) NOT REQUIRED D. Unreq. VOC's (Not Required) NOT REQUIRED E. SOC's (Not Required) NOT REQUIRED

7. Radioactivity (Not Required) NOT REQUIRED

8. Lead and Copper (Not Required) NO (Y/N)

9. Disinfection: YES (Y/N)

10. Has a Microscopic Particulate Analysis been completed on this source:

If yes, when 08/04/2009

YES (Y/N)

11. Remarks: NEED TO KEEP RECORDS OF BACTERIOLOGICAL AND

NITRATE TEST RESULTS

D. BASELINE TESTING

FSM 7421.24a requires a baseline testing of all potable water systems (no class differentiation) to analyze for all primary and secondary inorganic and organic contaminants listed in the National Interim Primary Drinking Water Regulations, National Secondary Drinking Water Regulations

(NSDWR).

W- 6

1. Primary Drinking Regulations

A. Inorganic Contaminants – Date Tested:

1. Arsenic: NO (Y/N)

2. Barium: NO (Y/N)

3. Cadmium: NO (Y/N)

4. Chromium: NO (Y/N)

5. Lead: NO (Y/N)

6. Mercury: NO (Y/N)

7. Nitrate (as N): NO (Y/N)

8. Selenium: NO (Y/N)

9. Silver: NO (Y/N)

10. Fluoride: NO (Y/N) B. Organic Contaminants: - Date Tested:

1. Chlorinated Hydrocarbons A. Endrin: NO (Y/N) B. Lindane: NO (Y/N) C. Methoxychlor: NO (Y/N) D. Toxaphene: NO (Y/N)

2. National Secondary Drinking Water Regulations (NSDWR) A. Aluminum: NO (Y/N) B. Chloride: NO (Y/N) C. Color: NO (Y/N) D. Copper: NO (Y/N) E. Corrosivity: NO (Y/N) F. Foaming Agent: NO (Y/N) G. Iron: NO (Y/N) H. Manganese: NO (Y/N) I. Odor: NO (Y/N) J. PH (At Site): NO (Y/N) K. Sulfate: NO (Y/N) L. Silver: NO (Y/N) M. TDs NO (Y/N) N. Zinc: NO (Y/N)

Remarks: NEED CHEMICAL ANALYSIS

W- 7

E. POTENTIAL SOURCE OF CONTAIMINANT WITHIN ONE HALF MILE OF A

WATER SOURCE

1. Agricultural Run-off: NO (Y/N)

2. Animal Feed Lots or Grazing: NO (Y/N)

3. Wastewater Treatment Plant Discharge NO (Y/N)

4. Hazardous Waste Site: NO (Y/N)

5. Solid Waste Disposal: NO (Y/N)

6. Pesticides, Rodenticides, Fungisides YES (Y/N)

7. Mining, Oil, or Gas Activities NO (Y/N)

8. Petroleum Products (eg., auto repair shop, gas station

(MTBE)):

NO (Y/N)

9. Septic System or other Wastewater System: YES (Y/N) 170 FEET

10. Is there a Source Water Protection Plan: NO (Y/N)

11. Logging in Last 10 Years: YES (Y/N)

12. Other (Please specify): NONE (Y/N)

13. Forest Fire in Last 10 Years: NO (Y/N)

14. Remarks: LOGGING DUE TO MOUNTAIN PINE

BEETLE

Note: If any of 1-9 are yes, note size, distance, protection measures, sources, and system components.

F. CERTIFIED OPERATOR: YES (Y/N)

1. Name STEVEN J. WOOD

2. License No. 36397

3. Class S-WATER SYSTEMS

G USE RECORDS

1. Water Shortage experienced: (If YES, explain): NO (Y/N)

2. Water meter readings available (If YES, provide copy): NO (Y/N)

3. Electrical meter readings available (If YES, provide copy): NO (Y/N)

4. Water meter reading worksheet (See Page WI-8): NONE (Y/N)

5. Electrical meter reading worksheet (See Page WI-9): N/A (Y/N)

6. Remarks:

W- 8

7. Water Meter Readings Worksheet (Last 5 Years)

MONTH/YEAR READING

(GALLONS OR

CUBIC FEET

USED (GALLONS

OR CUBIC FEET)

COST ($)

1. NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE

2.

3.

4.

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36.

37.

38.

39.

40.

W- 9

8. Electrical Meter Readings Worksheet (Last 5 Years)

MONTH/YEAR

USE (KW)

COSTS ($)

1. NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE

2.

3.

4.

5.

6.

7.

8.

9.

10.

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40.

W- 10

H. RECORDS

1. Operation and Maintenance

a. Scheduled operation and maintenance adequate NO (Y/N)

b. Preventive maintenance: NO (Y/N)

c. O&M records adequate: NO (Y/N)

d. O&M manual available: NO (Y/N)

e. Is there a maintenance log book?: NO (Y/N)

f. Maintenance responsibilities clearly defined: NO (Y/N)

g. Is there a sampling site plan: NO (Y/N)

h. Is there a cross-connection control plan: NO (Y/N)

Improvements needed: NEED OPERATIONS AND MAINTENANCE PLAN AND

DOCUMENT PREVENTATIVE MAINTENANCE ACTIVITIES. SUBSEQUENT TO

MODIFING THE SYSTEM, AN O&M MANUAL SHOULD DESCRIBE THE

SYSTEM COMPONETS AND THEIR OPERATION. START-UP AND SHUT-DOWN

PROCEDURES FOR SPRING AND FALL SHOULD BE INCLUDED. A

PERMANENT LOG OF INSPECTIONS, MAINTENANCE OPERATIONS, AND

CHANGES.

Remarks: WATER SYSTEM RECORDS SHOULD BE KEPT, AN ALL WEATHER

BOUND NOTE BOOK, IS RECOMMENDED. A DETAILED SKETCH OF THE

SYSTEM IS ALSO REQUIRED.

2. Sanitary Surveys:

a. Reason for Sanitary/Condition Survey: ROUTINE (Initial, Routine, Compliance)

b. Previous Sanitary/Condition Surveys YES (Y/N)

(MM DD YY) 09/13/2012

3. Water Rights

a. Are there water rights: YES (Y/N)

b. Water right name: WELL PERMIT

c. State File No.: N/A

d. Reserved water rights claimed: NO (Y/N)

Remarks: STATEMENT OF BENEFICIAL USE FOR 1/3 ACRE-FEET WITH WELL

PERMIT

4. Watershed

a. Watershed name: LARAMIE RIVER – STUB CREEK

b. Watershed code: 101800100102

W- 11

4. Record Retention--Are the following records being retained:

Records

Time Period

a. Sanitary/Condition Surveys 10 Years YES (Y/N)

b. Bacteriological Analysis 5 Years NO (Y/N)

c. Chemical Analysis *10 Years NO (Y/N)

d. Physical Analysis *10 Years NO (Y/N)

d. Variances or Exemptions 5 Years NO (Y/N)

e. Turbidity Results 10 Years NO (Y/N)

f. Violations 37 Years NO (Y/N)

*Life of system, unless a flood, earthquake, etc.)

I. ANNUAL OPERATIONS & MAINTENANCE WORKSHEET – DRINKING WATER

Key to Deferred Maintenance Tasks

Task Description Dollars Needed

Unit Remarks

01 Start Up 01-002001 Start Up - Source - Chlorinate and Flush Well

$111.85 EACH 2 HOURS

01 Start Up 01-004001 Start Up - Treatment - Flush and Fill Chlorinator/Treatment Plant

$86.27 EACH 1-1/2 HOURS

01 Start Up 01-005001 Start Up - Storage - Flush and Fill Pressure Tanks

$51.15 HOUR 1 HOUR

01 Start Up 01-005002 Start Up - Storage - Disinfect Storage Tank

$60.70 EACH 1 HOUR

01 Start Up 01-006001 Start Up - Disinfect Distribution Line - Disinfect and Drain all Distribution Lines

$519.14 EACH 10 HOURS

01 Start Up 01-006002 Start Up - Disinfect Distribution Line - Close Drains, Fill System, Operate all Valves

$204.60 EACH 4 HOURS

03 Operator Training & Certification

03-001001 Operator Training & Certification - Office

- Seasonal Training

$409.20 EACH 8 HOURS

03 Operator Training & Certification

03-001002 Operator Training & Certification - Office

- Confined Space Awareness Training

$102.30 EACH 2 HOURS

06 Condition Survey

06-001001 Condition Survey - Survey - Beginning of Season Inspection

$204.60 HOUR 4 HOURS

06 Condition Survey

06-001002 Condition Survey - Survey - End of Season Survey

$204.60 HOUR 4 HOURS

07 Sanitary Survey

07-001002 Sanitary Survey Survey - Surveys - Sanitary Survey/Condition Survey (FOREST

SERVICE)

$605.70 EACH 8 HOURS

08 System Operation

08-002001 System Operation - Pumps and Controls

- Weekly Check

$818.40 HOUR 16 HOURS

OVER THE

SEASON

08 System Operation

08-003001 System Operation - Treatment - Weekly Check

$818.40 HOUR 16 HOURS

OVER THE

SEASON

08 System Operation

08-003002 System Operation - Treatment - Chlorine Solution, Refill Tank

$409.20 HOUR 8 HOURS

OVER THE

SEASON

08 System Operation

08-004001 System Operation - Backflow Preventors

- Hose Bibb: Installation/Inspection/Replacement

$593.40 EACH 6 OUTSIDE

HOSE BIBBS

10 Sampling 10-002001 Sampling - Source - Startup Bacteriological Test

$89.35 EACH 1 TEST

W- 12

10 Sampling 10-002002 Sampling - Source - Monthly Bacteriological Test

$536.10 EACH 6 SAMPLES

10 Sampling 10-002003 Sampling - Source - Nitrate/Nitrite Test $453.13 EACH 1 TEST 10 Sampling 10-003001 Sampling - Treatment - Chlorine

Residual Test

$818.40 HOUR 16 HOURS

OVER THE

SEASON

11 Record Keeping

11-001001 Record Keeping - Office - INFRA Updates

$409.20 HOUR 8 HOURS

11 Record Keeping

11-001002 Record Keeping - Office - Water Quality Reports

$409.20 HOUR 8 HOURS

11 Record Keeping

11-001003 Record Keeping - Office - Well logs/As- Builts/O&M and Sampling Plans

$1,910.00 LS None

13 Consumables 13-001001 Consumables - Treatment - Chlorine Solution

$11.46 GAL. 6 GALLONS

14 Shut Down 14-003001 Shut Down - Treatment - Drain Chlorinator/Plant/Tank

$51.15 HOUR 1 HOUR

14 Shut Down 14-004001 Shut Down - Storage - Drain Pressure Tank

$51.15 HOUR 1 HOUR

14 Shut Down 14-005001 Shut Down - Distribution - Drain Seasonal System, Open/Shut Valves

$204.60 EACH 4 HOURS

W- 13

PART II

FIELD DATA FOR SANITARY/CONDITION SURVEY

Pawnee National Grassland

District : Canyon Lakes Ranger District

Forest Service, or State or EPA I.D. Number: 335219

Date Surveyed : August 27, 2018

Surveyed By : /s/ Chris Ida

PART II

ITEM NO. PAGE

PART II - FIELD DATA

IIA. Source W-14

1. Well W-14

2. Spring W-15

3. Surface W-15

4. Municipal W-16

IIB. Pumps W-16

1. Well W-16

2. Supply W-17

3. Handpump W-18

IIC. Treatment System W-19 IID. Storage System W-20 IIE. Distribution System W-21 IIF. Point of Use W-22 IIG. Electrical System W-25

W- 14

PART II - FIELD DATA

A. SOURCE

1. Well

a. Well permit number: 21449-A

b. Well log: YES (Y/N)

c. Location: SW¼, NE ¼ OF

SECTION 34

Latitude: 40.793056° Longitude: -105.905278° Section: 34 Township: 10 NORTH Range: 76 WEST

d. Type: (Dug, Driven, Jetted, Bored, Drilled) DRILLED

e. Casing:

Diameter: (inches, I.D) 4-1/2” Material: (Plastic, Steel, Other) STEEL/PVC Wall thickness: (inches) 0.237/SCH. 40

f. Depth:

Ground surface to bottom of well: 111.5 (FEET) Ground surface to bottom of casing: 111.0 (FEET) Ground surface to first draw (top of screen/perforations or bottom of casings)

90.6 (FEET)

Static water level: 53.4 (FEET) Pump set at UNKNOWN (FEET)

g. Capacity (gpm at feet drawdown) 25.5 GPM

h. Type of sanitary seal: (Cement Grout, Bentonite, Well Cutting, Other)

CEMENT

i. Subject to flooding: NO (Y/N)

j. Has well been evaluated for 100 year flood: NO (Y/N)

k. Is casing 18 inches above natural grade:

YES (Y/N)

l. Concrete slab around casing: NO (Y/N)

m. Well screen Material: (Plastic, Steel, Other) PVC Type: (Slotted, Drilled, Torch Cut) SLOTTED Hole/Slot Size: 0.020

n. Sanitary well cover type: (Cap, Seal) CAP Vented: YES (Y/N)

o. Pitless Adapter: YES (Y/N)

p. Located how far from a possible source of contamination

(subsurface sewage disposal field, septic tank, vault toilet, stream, lake, marsh or ditch)

170 FEET TO

LEACHFIELD

q. Has a microscope particulate analysis (MPA) been completed on this source:

If Yes, When: (mm/dd/yy)

YES (Y/N)

08/04/2009

Condition: (Critical, Poor, Satisfactory, Good) GOOD Appraisal: (Maintain, Remove, Repair, Replace) MAINTAIN

W- 15

Possible sources of contamination: LEACHFIELD APPROXIMATELY 170 FEET AWAY

FROM PUMPHOUSE

Improvements needed:

2. Spring

a. Location:

Latitude:

Longitude:

Section:

Township:

Range:

b. Type: (Flowing, Non-flowing, Intermittent)

c. Estimated minimum capacity (GPM)

d. Surface drainage controlled: (Y/N)

e. Adequate fencing around spring: (Y/N)

f. Spring box watertight: (Y/N)

g. Spring box cover:

1. Lockable: (Y/N)

2. Watertight: (Y/N)

3. Overhanging (shoe box lid): (Y/N)

4. Material: (Concrete, Steel, Other) (Y/N)

5. Gasket adequate: (Y/N)

h. Spring box vent screened: (Y/N)

i. Spring box drain screened: (Y/N)

j. Spring box - has overflow and drain pipe: (Y/N)

k. Spring/well permit number:

l. Does spring box have laterals or open gravel bottom (Y/N)

m. Has a microscopic Particulate Analysis (MPA) been completed on this source? If Yes, When: (MM/DD/YY) (Y/N)

Condition: (Critical, Poor, Satisfactory, Good) Appraisal: (Maintain, Remove, Repair, Replace)

Possible sources of contamination in watershed: (pesticide usage, logging, spills, or grazing):

3. Surface (Stream, River, or Lake)

a. Name (s) :

Location:

Latitude:

Longitude:

Section:

Township:

Range:

W- 16

b. Flow: (Perennial or Intermittent)

c. Upstream human activity on watershed: (Y/N)

d. Intake structure or impoundment provided: (Y/N)

e. Intake structure overflow and drain provided: (Y/N)

f. Intake screened: (Y/N)

g. Intake inaccessible to public: (Y/N)

h. Impoundment easily cleaned of sedimentation and debris: (Y/N)

i. Collection Method: (Infiltration Gallery, Surface Intake) Condition: (Critical, Poor, Satisfactory, Good) Appraisal: (Maintain, Remove, Repair, Replace)

Possible sources of contamination in watershed: (pesticide usage, logging, spills, grazing or fires)

4. Municipal:

a. Name of Water System:

b. Water System I.D. Number:

c. Name of Owner:

d. Have there been any reports of waterborne disease: If

Yes, give details (Y/N)

e. Have there been any violations in the past 3 years:

If Yes, What:

(Y/N)

f. Water Source: (Ground, Spring, Surface)

B. PUMPS:

1. Well

a. Manufacturer: UNKNOWN

b. Model: UNKNOWN

c. Diameter: UNKNOWN

d. Horsepower: UNKNOWN

e. RPM: UNKNOWN

f. FLA: UNKNOWN

g. S.F. UNKNOWN

h. Voltage: UNKNOWN

i. Phase: UNKNOWN

j. Running Time Meter: (hrs) ## (HOURS)

k. Pump Operational Counter: (counts) ## (COUNTS)

l. Operating properly: YES (Y/N)

m. Pump properly sized: YES (Y/N)

n. Pump curve provided: NO (Y/N)

o. Pumping Rate Capacity: UNKNOWN (GPM)

p. Year of Installation: 2000

q. Pump protection:

1. Conductors to motor properly sized: YES (Y/N)

2. Motor running current below nameplate rating: YES (Y/N)

3. Circuit breaker or fuse properly sized: YES (Y/N)

4. Motor starter overloads properly sized: YES (Y/N)

W- 17

5. Motor starter properly sized: YES (Y/N)

6. Hand-off-Automatic switch: NO (Y/N)

7. Operation light: NO (Y/N)

8. Pump operation timer: NO (Y/N)

9. Start and stop pump controls adequate: YES (Y/N)

10. Low liquid level shutoff (Storage tank system) YES (Y/N)

11. Low water level shut off in well: NO (Y/N)

r. Pump discharge piping:

1. Pressure gauge with shutoff: YES (Y/N)

2. Check valve: YES (Y/N)

3. Control and shutoff valve: NO (Y/N)

4. Flow control valve: NO (Y/N)

## (GPM)

5. Pressure Relief Valve: NO (Y/N) Setting: ## (PSI)

6. Pressure Regulating Valve NO (Y/N) Setting: ## (PSI) Condition: (Critical, Poor, Satisfactory, Good) SATISFACTORY Appraisal: (Maintain, Remove, Repair, Replace) MAINTAIN

2. Supply Pump (If there is a separate well and supply pump.)

a. Manufacturer: A.0.

SMITH/GOULDS

b. Model: C48A93A06/J04853L

c. Horsepower: 1/2 HP

d. RPM: 3450

e. FLA: 10.8/5.4 AMPS

f. S.F.: 1.6

g. Voltage: 115/230

h. Phase: SINGLE

i. Running Time Meter: (hrs) ## (HOURS)

j. Pump Operation Counter: (counts) ## (COUNTS)

k. Operating properly: YES (Y/N)

l. Pump properly sized: YES (Y/N)

m. Pump curve provided: NO (Y/N)

n. Pumping Rate Capacity: 4 GPM

o. Year of Installation: 2000

p. Pump protection:

1. Conductors to motor properly sized: YES (Y/N)

2. Motor running current below nameplate rating: YES (Y/N)

3. Circuit breaker or fuse properly sized: YES (Y/N)

4. Motor starter overloads properly sized: YES (Y/N)

5. Motor starter properly sized: YES (Y/N)

6. Hand-off-Automatic switch: NO (Y/N)

7. Operation light: NO (Y/N)

W- 18

8. Pump operation counter: NO (Y/N)

9. Start and stop pump controls adequate: YES (Y/N)

10. Low liquid level shutoff (Storage tank system) YES (Y/N)

q. Pump discharge piping:

1. Pressure gauge with shutoff: YES (Y/N)

2. Check valve type: (Swing, Poppet, Disk) NONE

3. Control and shutoff valve: NO (Y/N)

4. Flow control valve: N/A (GPM) Condition: (Critical, Poor, Satisfactory, Good) GOOD Appraisal: (Maintain, Remove, Repair, Replace) MAINTAIN

3. Handpump

a. Drainage

1. Drain pipe or trough clean: NONE (Y/N)

2. Excess water drains away from slab area: NONE (Y/N)

3. Surface water drains away from slab area: NONE (Y/N)

b. Slab

1. Open cracks in slab: NONE (Y/N)

2. Rodents burrowing under slab: NONE (Y/N)

3. Is there an open gap between the well casing and the slab: NONE (Y/N)

c. Pump Stand

1. Nuts and bolts on stand are tight: NONE (Y/N)

2. Pump secured to concrete slab or casing: NONE (Y/N)

d. Packing Nut and Packing (Stuffing Box)

1. Is there packing: NONE (Y/N)

2. Packing nut tight (tightened enough so there is no side movement):

NONE (Y/N)

3. Is packing in good condition: NONE (Y/N)

e. Upper Piston Guide

1. Is there more than 1/8 inch of play between guide and rod in the direction of the pump handle:

NONE (Y/N)

f. Pump Flanges

1. Check for presence of flange gasket. Can usually tell by gap between flanges and probing with a knife:

NONE (Y/N)

2. Is gasket in good condition? No cracks, etc: NONE (Y/N)

g. 1. Is pump located near a stream, lake, marsh, septic system, or toilet, etc:

NONE (Y/N)

2. How far from one of the above: NONE

h. Bubble reservoir clean: NONE (Y/N)

i. If pump outlet pipe is threaded, is there an anti-siphon device used:

NONE

j. Is a shroud installed on the pump: NONE (Y/N)

k. Year of installation: NONE Condition: (Critical, Poor, Satisfactory, Good) Appraisal: (Maintain, Remove, Repair, Replace) Possible sources of contamination:

W- 19

C. TREATMENT SYSTEM

1. Type of disinfection: (Chlorine, Iodine, Ozone, Other) CHLORINE

2. Sedimentation: NO (Y/N)

3. Filtration: NO (Y/N)

4. Filter material: (Sand or Other medium) N/A

5. Equipment Flow Rate: NO (Y/N)

6. Treatment being provided in accordance with FSM 7420 and State

Drinking Water Design Criteria:

YES (Y/N)

7. Treatment equipment adequate: YES (Y/N)

8. Treatment equipment operating properly: YES (Y/N)

9. Test equipment adequate: NO (Y/N)

10. Disinfection contact time adequate: YES (Y/N)

11. Treatment building or enclosure:

a. Inaccessible to public: YES (Y/N)

b. Ventilation adequate: YES (Y/N)

c. Heating adequate: PORTABLE ELECTRIC YES (Y/N)

d. Drainage adequate: YES (Y/N)

12. Disinfection Unit: YES (Y/N)

a. Manufacturer STENNER PUMP

CO.

Phone No. 800-683-2378

b. Model Number: 45MHP2

c. Discharge Flow: (gals./day) 3.0 (GALS/DAY)

d. Spare parts: NO (Y/N)

e. Records kept of disinfectant residual NO (Y/N)

f. Type (Pressure, Water, Electric, Tablet, Other) ELECTRIC

g. Protective equipment available:

1. Rubber gloves: NO (Y/N)

2. Face Shield: NO (Y/N)

3. Eye Bath: NO (Y/N)

h. Testing chlorine residual for total chlorine: NO (Y/N)

13. Disinfection monitor waiver: N/A (Y/N) Condition: (Critical, Poor, Satisfactory, Good) SATISFACTORY

Improvements:

W- 20

D. STORAGE SYSTEM

1. Tank Type: (Hydropneumatic, Elevated, Below Ground) ELEVATED /

HYDROPNEUMATIC

Manufacturer: ELEVATED-POLYETHYLENE TFI

INTERNATIONAL

Model No:

Manufacturer: HYDRO-PNUEMATIC Model No:

CUSTOM

WELL-X-TROL

WX-302

2. Material of construction: (Steel, Concrete, Wood, Fiberglass, Polyethylene)

POLYETHYLENE /

STEEL

3. Capacity adequate for:

a. Domestic: YES (Y/N)

b. Fire: NO (Y/N)

c. Irrigation: NO (Y/N)

d. Capacity: 1000/86 (GALS)

e. Dimensions: (l x w x h) inches ELEVATED

Dimensions: (l x w x h) inches WELL-X-TROL

5’x5’x5’ 26” DIA.x47” H

4. Vent with return bend and screened: NO (Y/N)

5. Is screen size 24 mesh or smaller: N/A (Y/N)

6. Outlet through tank bottom: YES (Y/N)

7. Outlet off the bottom: YES (Y/N)

8. Tank inlet and outlet separate: YES (Y/N)

9. Tank inlet and outlet insulated: NO (Y/N)

10. Overflow pipe provided: NO (Y/N)

11. Overflow properly daylighted and screened: N/A (Y/N)

12. Tank drain through bottom YES (Y/N)

13. Tank drain separate from inlet and outlet: YES (Y/N) 14 Drain properly daylighted and screened: NO (Y/N)

15. Access cover:

a. Lockable: NO (Y/N)

b. Watertight: YES (Y/N)

c. Overhanging (shoebox type): YES (Y/N)

d. If bolted, are all the bolts in place: N/A (Y/N)

e. Is gasket adequate: N/A (Y/N)

16. Exterior ladder serviceable:

a. Climb prevention device adequate: N/A (Y/N)

17. Interior ladder:

a. Provided: NO (Y/N)

b. Serviceable: N/A (Y/N)

18. Roof watertight: YES (Y/N)

19. Steel tanks:

a. Interior paint adequate: YES (Y/N)

b. Exterior paint adequate: YES (Y/N)

20. Concrete tanks:

a. Protective coating adequate: N/A (Y/N)

b. Concrete watertight: N/A (Y/N)

c. Tank interior painting system NSF of ANSI approved: N/A (Y/N)

W- 21

21. Liquid level controls adequate: YES (Y/N)

22. Level control type: (Probes, Floats) FLOATS

23. Level control manufacturer: UNKNOWN

24. Level control model number: UNKNOWN

25. Low level alarm provided: NO (Y/N)

26. Volume gauge provided: NO (Y/N)

27. Pressure relief valve on hydropneumatic tank: YES (Y/N)

a. Is the valve sized properly: YES (Y/N)

28. Confined space plan in place for this tank: NO (Y/N) Condition: (Critical, Poor, Satisfactory, Good) SATISFACTORY

E. DISTRIBUTION SYSTEM

1. Pipe material: (PVC, Polyethylene, Ductive Iron, Copper) PVC, COPPER

2. Approximate length of piping system UNKNOWN (FEET)

3. Pressure at all fixtures adequate: YES (Y/N) If no, explain:

4. Pressure rating/other: (PSI Pressure Rating, SDR, Class, or

Schedule)

UNKNOWN

5. Pressure regulator provided: NO (Y/N)

6. Air relief valve (s) provided: NO (Y/N)

7. Vacuum relief valve (s) provided: NO (Y/N)

8. Drains to daylight: YES (Y/N)

9. Pumped Drain: NO (Y/N)

10. Drains screened: NO (Y/N)

11. Lines adequately buried: YES (Y/N)

12. Water pipe NSF approved: YES (Y/N)

13. Adequate coverage with fire hydrants: N/A (Y/N)

14. Water hammer arrestors provided: NO (Y/N)

15. Water meter provided: NEPTUNE, T-10, 1-INCH YES (Y/N)

16. Tap for obtaining sample of raw water provided: YES (Y/N)

17. Access point for adding disinfectant provided: YES (Y/N)

18. Valve pits - free of water: N/A (Y/N)

19. Is there an interconnection with any other system: NO (Y/N) If yes, explain: (Y/N) Condition: (Critical, Poor, Satisfactory, Good) SATISFACTORY

Possible sources of contamination:

W- 22

F. POINT OF USE

1. Type: (Hydrant, Fountain, Hydrant & Fountain) HYDRANT P1 TO P3 IN PUMPHOUSE

a. Manufacturer: UNKNOWN Phone: UNKNOWN

b. Model No: UNKNOWN c.. Accessibility Status: (Not-Accessible, Usable, Accessible) NOT-ACCESSIBLE

d. Drainage:

1. Drain pipe or trough clean: N/A (Y/N)

2. Excess water drains away from slab area: N/A (Y/N)

3. Surface water drains away from slab area: N/A (Y/N)

e. Slab:

1. Open cracks in slab: N/A (Y/N)

2. Rodents burrowing under slab: N/A (Y/N) Condition: (Critical, Poor, Satisfactory, Good) SATISFACTORY Appraisal: (Maintain, Remove, Repair, Replace) MAINTAIN

Improvements: NEW BACKFLOW PREVENTORS ON TWO OF THE THREE FAUCETS IN

PUMPHOUSE

Type: (Hydrant, Fountain, Hydrant & Fountain) HYDRANT H2. OUTDOOR HYDRANT

BLDG. #404 - GARAGE/SHOP

a. Manufacturer: UNKNOWN Phone: UNKNOWN

b. Model No: UNKNOWN c.. Accessibility Status: (Not-Accessible, Usable, Accessible) NOT-ACCESSIBLE

d. Drainage:

1. Drain pipe or trough clean: N/A (Y/N)

2. Excess water drains away from slab area: N/A (Y/N)

3. Surface water drains away from slab area: N/A (Y/N)

e. Slab:

1. Open cracks in slab: N/A (Y/N)

2. Rodents burrowing under slab: N/A (Y/N) Condition: (Critical, Poor, Satisfactory, Good) SATISFACTORY Appraisal: (Maintain, Remove, Repair, Replace) MAINTAIN

Improvements: NEW BACKFLOW PREVENTORS ON OUTDOOR HYDRANT

Type: (Hydrant, Fountain, Hydrant & Fountain) BLDG. #406. BUNKHOUSE (4 TOILET, 4

LAVATORIES, 4 SHOWERS, 1 WASHER

HOOKUP, 1 UTILITY SINK, 2 KITCHEN

SINKS, 1 EXTERIOR HOSE BIBB-HOST)

W- 23

a. Manufacturer: UNKNOWN Phone: UNKNOWN

b. Model No: UNKNOWN c.. Accessibility Status: (Not-Accessible, Usable, Accessible) NOT-ACCESSIBLE

d. Drainage:

1. Drain pipe or trough clean: N/A (Y/N)

2. Excess water drains away from slab area: N/A (Y/N)

3. Surface water drains away from slab area: N/A (Y/N)

e. Slab:

1. Open cracks in slab: N/A (Y/N)

2. Rodents burrowing under slab: N/A (Y/N) Condition: (Critical, Poor, Satisfactory, Good) SATISFACTORY Appraisal: (Maintain, Remove, Repair, Replace) MAINTAIN

Type: (Hydrant, Fountain, Hydrant & Fountain) BLDG. #402 RANGER HOUSE (1

TOILET, 1 LAVATORY, 1 SHOWER,

1 KITCHEN SINK, 1 UTILITY SINK-

INACTIVE, 3 EXTERIOR HOSE BIBBS)

a. Manufacturer: UNKNOWN Phone: UNKNOWN

b. Model No: UNKNOWN c.. Accessibility Status: (Not-Accessible, Usable, Accessible) NOT-ACCESSIBLE

d. Drainage:

1. Drain pipe or trough clean: N/A (Y/N)

2. Excess water drains away from slab area: N/A (Y/N)

3. Surface water drains away from slab area: N/A (Y/N)

e. Slab:

1. Open cracks in slab: N/A (Y/N)

2. Rodents burrowing under slab: N/A (Y/N) Condition: (Critical, Poor, Satisfactory, Good) SATISFACTORY Appraisal: (Maintain, Remove, Repair, Replace) MAINTAIN

Improvements: REMOVE INACTIVE UTILITY SINK. REMOVE ONE EXTERIOR HOSE

BIBB AND INSTALL BACKFLOW PREVENTORS ON REMAING TWO HOSE BIBBS.

Type: (Hydrant, Fountain, Hydrant & Fountain) BLDG. #403 OFFICE (1 TOILET, 1

LAVATORY, 1 SHOWER, 1 KITCHEN

SINK, 1 EXTERIOR YARD HYDRANT

W- 24

Phone: UNKNOWN

b. Model No: UNKNOWN c.. Accessibility Status: (Not-Accessible, Usable, Accessible) NOT-ACCESSIBLE

d. Drainage:

1. Drain pipe or trough clean: N/A (Y/N)

2. Excess water drains away from slab area: N/A (Y/N)

3. Surface water drains away from slab area: N/A (Y/N)

e. Slab:

1. Open cracks in slab: N/A (Y/N)

2. Rodents burrowing under slab: N/A (Y/N) Condition: (Critical, Poor, Satisfactory, Good) SATISFACTORY Appraisal: (Maintain, Remove, Repair, Replace) MAINTAIN

2. Host Site Hydrant

Phone: UNKNOWN

b. Model No: UNKNOWN

c. Accessibility Status:(Not-Accessible, Usable, Accessible) NOT-ACCESSIBLE

d. Number of Host Sites: TWO

e. How Many have water: TWO

f. Drainage:

1.Drain pipe or trough clean: N/A (Y/N) 2.Excess water drains away from slab area: N/A (Y/N) 3.Surface water drains away from slab area: N/A (Y/N)

g. Slab:

1.Open cracks in slab: N/A (Y/N) 2.Rodents burrowing under slab: N/A (Y/N) Condition: (Critical, Poor, Satisfactory, Good) SATISFACTORY Appraisal: (Maintain, Remove, Repair, Replace) MAINTAIN

Improvements: INSTALL BACKFLOW PREVENTOR ON EXTERIOR HOST HYDRANTS

3. RV Site Hydrant

a. Manufacturer:

Phone:

b. Model No:

c. Accessible Status: (Not-Accessible, Usable, Accessible)

d. Number of RV sites:

e. How many have water:

Condition: (Critical, Poor, Satisfactory, Good)

W- 25

4. Trailer Dump Station Tower (Drinking Water)

a. Manufacturer:

Phone no:

b. Model No:

c. Does the drinking water tower have a backflow device: (Y/N) Condition: (Critical, Poor, Satisfactory, Good)

5. If the outlets are threaded, are there any backflow prevention devices used: NO (Y/N)

a. If Yes, manufacturer: N/A (Y/N) Phone: N/A (Y/N)

b. Model No: N/A (Y/N) Condition: (Critical, Poor, Satisfactory, Good) POOR Appraisal: (Maintain, Remove, Repair, Replace) REPLACE

Remarks: INSTALL BACKFLOW PREVENTORS ON FAUCETS P1, P2, IN PUMPHOUSE, AND ALL EXTERIOR HOSE BIBBS AND YARD HYDRANTS.

6. Are frost proof Hydrants NSF approved: YES (Y/N)

Phone: UNKNOWN

b. Model No: UNKNOWN Condition: (Critical, Poor, Satisfactory, Good) SATISFACTORY

Remarks: BACKFLOW PREVENTORS ON YARD HYDRANTS

7. If this system serves any stock watering tanks, is there backflow prevention:)

Note: (Air gaps are not approved Backflow Prevention) Possible Sources of Contamination:

Improvements Needed:

G. ELECTRICAL SYSTEM

1. Power Source:

a. Utility Name: POUDRE VALLEY

REA

Phone No.: 800-432-1012

1. Characteristics:

Voltage: UNKNOWN Overhead: YES (Y/N) Underground: NO (Y/N)

2. Transformer:

Ownership POUDRE VALLEY

REA

W- 26

Voltage: UNKNOWN Phase: UNKNOWN Capacity: UNKNOWN Impedance: UNKNOWN

b. Generator Manufacturer: N/A Phone No: N/A Model: N/A Rating: (KW 120/240, phases) N/A

c. Photovoltaic:

Panel Manufacturer Phone No:

Number of Panels:

Watts (ea):

Size:

2. Distribution: (From Meter) (Overhead/Underground): OVERHEAD

3. Host Site Power

a. Power Pedestal or box:

1. Manufacturer:

Phone:

2. Model No.:

3. How many host sites:

4. How many have power:

5. Main receptacle amperage:

6. Receptacle amperage:

Condition: (Critical, Poor, Satisfactory, Good) Appraisal: (Maintain, Remove, Repair, Replace)

4. RV Site Power

a. Power pedestal or box:

1. Manufacturer:

Phone:

2. Model No.:

3. How many host sites:

4. How many have power:

5. Main receptacle amperage:

6. Receptacle amperage:

Condition: (Critical, Poor, Satisfactory, Good) Appraisal: (Maintain, Remove, Repair, Replace)

W- 27

PART III

REPORT ON SANITARY/CONDITION SURVEY

(A copy of the Sanitary/Condition Survey, Parts I, II, and III, should be attached to this report.)

Pawnee National Grassland

District : Canyon Lakes Ranger District

Forest Service, or State or EPA I.D. Number: 335219

Date of Survey : August 27, 2018

Survey Made By : /s/ Chris Ida

Date of this Report : March 22, 2019

Report Made By : /s/ Chris Ida

Reviewed By: Date:

District Ranger

Recreation Staff

Forest Engineer

PART III

ITEM NO. PAGE

PART III - FIELD DATA

IIIA. Site Identification W-28 IIIB. System Description W-28 IIIC. Attachments W-30

W- 28

REPORT OUTLINE

PART III – FIELD DATA

A. Site Identification

1. Forest: Arapaho and Roosevelt National Forest and

Pawnee National Grassland

2. Ranger District: Canyon Lakes Ranger District

3. Water System Identification Number: 335219

4. Type of Sites Served:

(Special Use, Admin., Recreation, Other) Administrative

5. Maximum Number of Persons using System per Day: (Persons/Day) 15 Persons at One Time

6. How many days are the persons in number 5 actually using the system: 153 Days

7. Use Period: June 1 to October 31 (mm/dd)

B. System Description

The Stub Creek Workcenter water system is a seasonal administrative site typically open from June to October that is a non-public, transient water system. The system consists of a 111.5 feet well, pumphouse with submersible pump and controls, above ground polyethylene storage tank with water level probes, booster supply pump, chlorine pump and tank, hydropneumatic storage tank, and a distribution system that serves 3 buildings. The existing well was drilled in 1999 by the Bureau of Reclamation. A well permit application and drillier log was submitted to the State Division of Water Resources as a follow-up under well permit 21449-A

The existing 111.5-feet deep, 4-1/2-inch diameter well is located southwest of the intersection of roads NFSR 193.0 and NFSR 193.4.

Water from the well is pumped via a submersible pump to the above ground polyethylene storage tank located in the Pumphouse. Water is controled by loats in the above ground tank. A booster/supply pump water to the distribution system and has associated pressure tanks/filtration/chlorination/valve components prior to entering the distibution system. No submersible pump information was available at the time of this sampling event; however, the pump appears to be sized and operating correctly and there is adequate pump protection. Water flow from the above ground storage tank is controlled by a pressure switch. There are no supply pump controls other then the pressure switch. A flo-logic leak alarm system is installed in the pumphouse to detect within the water system.

There is a chlorinator/chlorine solution tank on site for the water system and a fitting in the suply line to

W- 29 accommodate chlorine injection.

The water then flows from the Pumphouse to the distribution system and to the remaining 3 building facilities (with varied points of use)..

W- 30

Stub Creek Work Center Water System – Wellhead

Stub Creek Work Center Water System – Building #407 (Pumphouse)

W- 31

Stub Creek Work Center Water System – Pumphouse Building #407. Elevated Storage Tank, Submersible Pump Controls, Supply Pump, and Pressure Tank

Stub Creek Work Center Water System – Pumphouse Building #407. Clorination Unit and Pressure Tank

W- 32

Stub Creek Work Center Water System – Pumphouse Building #407. Polyethylene Storage Tank

Stub Creek Work Center Water System – Pumphouse Building #407. Hydrant P1

W- 33

Stub Creek Work Center Water System – Pumphouse Building #407. Hydrant P2

Stub Creek Work Center Water System – Pumphouse Building #407. Hydrant P3

W- 34

Stub Creek Work Center Water System – Pumphouse Building #407. Supply/Booster Pump

Stub Creek Work Center Water System – Pumphouse Building #407. Flo-logic Leak Detector

W- 35

Stub Creek Work Center Water System – Pumphouse Building #407. Flo-logic Leak Detector Controls

Stub Creek W Work Center ater System – Pumphouse Building #407. Pump Controls

W- 36

Stub Creek Work Center Water System – Pumphouse Building #407. Daylight Drain Valve Box

Stub Creek Work Center Water System – Pumphouse Building #407. Daylight Drain (Needs Screen)

W- 37

Stub Creek Work Center Water System – Bunkhouse Building #406. Mens Bathroom Toilets

Stub Creek Work Center Water System – Bunkhouse Building #406. Mens Bathroom Lavatories

W- 38

Stub Creek Work Center Water System – Bunkhouse Building #406. Mens Showers

Stub Creek Work Center Water System – Bunkhouse Building #406. Womens Toilets

W- 39

Stub Creek Work Center Water System – Bunkhouse Building #406. Womens Lavatories

Stub Creek Work Center Water System – Bunkhouse Building #406. Womens Showers

W- 40

Stub Creek Work Center Water System – Bunkhouse Building #406. Washer Hookup

Stub Creek Work Center Water System – Bunkhouse Building #406. Kitchen Sink

W- 41

Stub Creek Work Center Water System – Bunkhouse Building #406. Kitchen Sink

Stub Creek Work Center Water System – Bunkhouse Building #406. Utility Sink

W- 42

Stub Creek Work Center Water System – Bunkhouse Building #406. Exterior Hose Bibb (Host Site)

Stub Creek Work Center Water System – Bunkhouse Building #406. Building Manifold and Shutoff Valve

W- 43

Stub Creek Work Center Water System – Disconnected Yard Hydrant that needs to Removed

Stub Creek Work Center Water System – Valve Boxes

W- 44

Stub Creek Work Center Water System – Garage/Shop Building #404. Outdoor Yard Hydrant

Stub Creek Work Center Water System –Ranger House#402

W- 45

Stub Creek Work Center Water System – Ranger House #402. Bathroom

Stub Creek Work Center Water System – Ranger House #402. Kitchen Sink

W- 46

Stub Creek Work Center Water System – Ranger House #402. Utility Sink (Inactive and needs to be Removed)

Stub Creek Work Center Water System – Ranger House #402. Exterior Hydrants

W- 47

Stub Creek Work Center Water System – Office Building #403. Outdoor Yard Hydrant

Stub Creek Work Center Water System – Office Building #403. Bathroom

W- 48

Stub Creek Work Center Water System – Office Building #403. Bathroom Shower

Stub Creek Work Center Water System – Office Building #403. Kitchen Sink

W- 49

Stub Creek Work Center Water System – Daylight Drains and Valve Boxes

W- 50

Stub Creek Workcenter Water System – Site Plan

W- 51

Stub Creek Work Center Water System – Well Log (Bureau of Redclamation)

WATER SYSTEM

Annual / Deferred Maintenance Cost Summary Form

Forest: Arapaho and Roosevelt NF and Pawnee NG Water System Name: Stub Creek Work Center Water System District: Canyon Lakes RD Site Id: 400 Admin. Org 21005 Date: 8/27/2018 By: C.Ida

ANNUAL MAINTENANCE TASKS

Key to Deferred Maintenance Tasks

Task Description Dollars Needed

Unit Task Type Reason Priority Remarks

01 Start Up 01-002001 Start Up - Source - Chlorinate and Flush Well $111.85 EACH Annual Health and Safety Critical 2 HOURS 01 Start Up 01-004001 Start Up - Treatment - Flush and Fill

Chlorinator/Treatment Plant $86.27 EACH Annual Health and Safety Critical 1-1/2 HOURS

01 Start Up 01-005001 Start Up - Storage - Flush and Fill Pressure Tanks

$51.15 HOUR Annual Health and Safety Critical 1 HOUR

01 Start Up 01-005002 Start Up - Storage - Disinfect Storage Tank $60.70 EACH Annual Health and Safety Critical 1 HOUR 01 Start Up 01-006001 Start Up - Disinfect Distribution Line - Disinfect and Drain all Distribution Lines $519.14 EACH Annual Health and Safety Critical 10 HOURS

01 Start Up 01-006002 Start Up - Disinfect Distribution Line - Close Drains, Fill System, Operate all Valves

$204.60 EACH Annual Health and Safety Critical 4 HOURS

03 Operator Training & Certification

03-001001 Operator Training & Certification - Office - Seasonal Training

$409.20 EACH Annual Health and Safety Critical 8 HOURS

03 Operator Training & Certification

03-001002 Operator Training & Certification - Office - Confined Space Awareness Training

$102.30 EACH Annual Health and Safety Critical 2 HOURS

06 Condition Survey 06-001001 Condition Survey - Survey - Beginning of Season Inspection

$204.60 HOUR Annual Health and Safety Critical 4 HOURS

06 Condition Survey 06-001002 Condition Survey - Survey - End of Season Survey

$204.60 HOUR Annual Health and Safety Critical 4 HOURS

07 Sanitary Survey 07-001002 Sanitary Survey Survey - Surveys - Sanitary Survey/Condition Survey (FOREST SERVICE)

$605.70 EACH Annual Health and Safety Critical 8 HOURS

08 System Operation 08-002001 System Operation - Pumps and Controls - Weekly Check

$818.40 HOUR Annual Health and Safety Critical 16 HOURS OVER

THE SEASON

08 System Operation 08-003001 System Operation - Treatment - Weekly Check

$818.40 HOUR Annual Forest Mission Non-Critical 16 HOURS OVER

THE SEASON

08 System Operation 08-003002 System Operation - Treatment - Chlorine Solution, Refill Tank

$409.20 HOUR Annual Health and Safety Critical 8 HOURS OVER

THE SEASON

08 System Operation 08-004001 System Operation - Backflow Preventors - Hose Bibb: Installation/Inspection/Replacement

$593.40 EACH Annual Health and Safety Critical 6 OUTSIDE HOSE

BIBBS

10 Sampling 10-002001 Sampling - Source - Startup Bacteriological Test

$89.35 EACH Annual Health and Safety Critical 1 TEST

10 Sampling 10-002002 Sampling - Source - Monthly Bacteriological Test

$536.10 EACH Annual Health and Safety Critical 6 SAMPLES

10 Sampling 10-002003 Sampling - Source - Nitrate/Nitrite Test $453.13 EACH Annual Health and Safety Critical 1 TEST 10 Sampling 10-003001 Sampling - Treatment - Chlorine Residual

Test $818.40 HOUR Annual Health and Safety Critical 16 HOURS OVER

THE SEASON

11 Record Keeping 11-001001 Record Keeping - Office - INFRA Updates $409.20 HOUR Annual Forest Mission Critical 8 HOURS 11 Record Keeping 11-001002 Record Keeping - Office - Water Quality

Reports $409.20 HOUR Annual Forest Mission Critical 8 HOURS

11 Record Keeping 11-001003 Record Keeping - Office - Well logs/As- Builts/O&M and Sampling Plans

$1,910.00 LS Annual Forest Mission Critical None

13 Consumables 13-001001 Consumables - Treatment - Chlorine Solution $11.46 GAL. Annual Health and Safety Critical 6 GALLONS 14 Shut Down 14-003001 Shut Down - Treatment - Drain

Chlorinator/Plant/Tank $51.15 HOUR Annual Health and Safety Critical 1 HOUR

14 Shut Down 14-004001 Shut Down - Storage - Drain Pressure Tank $51.15 HOUR Annual Health and Safety Critical 1 HOUR 14 Shut Down 14-005001 Shut Down - Distribution - Drain Seasonal

System, Open/Shut Valves $204.60 EACH Annual Health and Safety Critical 4 HOURS

00 Blank ****** $0.00 ***** ***** ***** ***** None 00 Blank ****** $0.00 ***** ***** ***** ***** None 00 Blank ****** $0.00 ***** ***** ***** ***** None 00 Blank ****** $0.00 ***** ***** ***** ***** None

TOTAL ANNUAL OPERATION AND MAINTENANCE

COSTS $10,143.23

Water System Name: Stub Creek Work Center Water System

DEFERRED MAINTENANCE TASKS / CAPITAL IMPROVEMENTS (CONTINUED)

Key to Deferred Maintenance Tasks

Task Description Dollars Needed

Unit Task Type Reason Priority Remarks

04 Repair 04-005001 Repair - Storage - Reservoir Cleaning, Professional

$9,652.30 EACH Deferred Maintenance Forest Mission Non-Critical CLEAN STORAGE

TANK

04 Repair 04-006004 Repair - Distribution - Annual Backflow Preventor Inspection

$1,759.80 EACH Deferred Maintenance Forest Mission Non-Critical BACKFLOW

PREVENTORS AT

PUMPHOUSE,

NEW HOUSE,

YARD HYDRANT (6

TOTAL)

00 Blank ***** $0.00 ***** ***** ***** ***** None 00 Blank ***** $0.00 ***** ***** ***** ***** None 00 Blank ***** $0.00 ***** ***** ***** ***** None 00 Blank ***** $0.00 ***** ***** ***** ***** None 00 Blank ***** $0.00 ***** ***** ***** ***** None 00 Blank ***** $0.00 ***** ***** ***** ***** None 00 Blank ***** $0.00 ***** ***** ***** ***** None 00 Blank ***** $0.00 ***** ***** ***** ***** None 00 Blank ****** $0.00 ***** ***** ***** ***** None 00 Blank ****** $0.00 ***** ***** ***** ***** None 00 Blank ****** $0.00 ***** ***** ***** ***** None 00 Blank ****** $0.00 ***** ***** ***** ***** None

TOTAL DEFERRED MAINTENANCE COSTS $11,412.10