ADEQ Form DWAR1GR "Drinking Water Analysis Reporting Form - Ground Water Rule - Triggered Source Water Monitoring" - Arizona

What Is ADEQ Form DWAR1GR?

This is a legal form that was released by the Arizona Department of Environmental Quality - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2017;
  • The latest edition provided by the Arizona Department of Environmental Quality;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of ADEQ Form DWAR1GR by clicking the link below or browse more documents and templates provided by the Arizona Department of Environmental Quality.

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Download ADEQ Form DWAR1GR "Drinking Water Analysis Reporting Form - Ground Water Rule - Triggered Source Water Monitoring" - Arizona

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DRINKING WATER ANALYSIS REPORTING FORM
GROUND WATER RULE
Triggered Source Water Monitoring
*** Raw Well Water only – Only one well per form ***
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
[_______________]
________________________________________________
PWS ID Number
PWS Name
[_______________]
[_____:________]
________________________________________________
Sample Date
Sample Time
Owner/Contact Person
(24HR CLOCK)
__________________________________
(_____)__________________________________
Owner/Contact Email Address
Owner/Contact Phone Number
[________________]
[__________________]
REQUIRED: Well Number 55 -
Original Lab Specimen ID
DUAL PURPOSE * SAMPLE ONLY:
TYPE OF SAMPLE – Check One
Sample being used as:
Dual Purpose Sample taken at the Well *
(Only PWS serving < 1,000
RTCR [_______] UP
people or less and a single groundwater source. MUST HAVE REGULATORY
AGENCY APPROVAL.)
RTCR [_______] DN
GWR Triggered Source Sample(s)
GWR Additional Source Water Monitoring Samples (5 per well)
A positive Fecal Indicator result is an
Replacement GWR Sample (if original was invalidated) for
ACUTE VIOLATION requiring public notice.
Lab Specimen ID at top -
MUST HAVE REGULATORY AGENCY APPROVAL
** CONTACT ADEQ IMMEDIATELY. **
*** MICROBIOLOGICAL GWR FECAL INDICATORS ANALYSIS ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
Sample
Total
3100
Analysis
Analysis Start
3014 3002 3028
1
Collection
Cl
Complete
Total Coliform
Specimen ID
2
2
Fecal Indicators
mg/L
Date
Time
P / A / NA
Method
Result
Date
Time
Date
Time
1 - Use only when method provides TC and E. coli results.
2 - See page 2 for Fecal Indicator Analyte Code and Method Citation. Check one box.
*** LABORATORY INFORMATION ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
[________________________]
Specimen Number
Comment [___________________________________________]
Lab ID Number [AZ________]
Lab Name [_______________________]
Phone Number [_________________]
Lab Contact, Printed Name [___________________]
Authorized Signature [________________________________]
PWS Notification Date [________________]
PWS Person Notified [_____________________________________]
Any positive routine or increased routine RTCR sample triggers the GWR and requires ADEQ notification:
ADEQ Notification Date [_______________]
ADEQ Person Notified [____________________________________]
PLEASE DO NOT SUBMIT
Submit completed form to:
MULTIPLE TIMES
EMAIL:
WQD_Compliance_Data@azdeq.gov
-or- MAIL: ADEQ Water Quality Compliance Data Unit (MC 5415B-1),
For questions call: (602) 771-9200
1110 W. Washington St., Phoenix, AZ 85007.
DWAR 1GR: Revised 12/2017
DRINKING WATER ANALYSIS REPORTING FORM
GROUND WATER RULE
Triggered Source Water Monitoring
*** Raw Well Water only – Only one well per form ***
PUBLIC WATER SYSTEM INFORMATION
***
***
>>>> TO BE FILLED OUT BY SYSTEM PERSONNEL <<<<
[_______________]
________________________________________________
PWS ID Number
PWS Name
[_______________]
[_____:________]
________________________________________________
Sample Date
Sample Time
Owner/Contact Person
(24HR CLOCK)
__________________________________
(_____)__________________________________
Owner/Contact Email Address
Owner/Contact Phone Number
[________________]
[__________________]
REQUIRED: Well Number 55 -
Original Lab Specimen ID
DUAL PURPOSE * SAMPLE ONLY:
TYPE OF SAMPLE – Check One
Sample being used as:
Dual Purpose Sample taken at the Well *
(Only PWS serving < 1,000
RTCR [_______] UP
people or less and a single groundwater source. MUST HAVE REGULATORY
AGENCY APPROVAL.)
RTCR [_______] DN
GWR Triggered Source Sample(s)
GWR Additional Source Water Monitoring Samples (5 per well)
A positive Fecal Indicator result is an
Replacement GWR Sample (if original was invalidated) for
ACUTE VIOLATION requiring public notice.
Lab Specimen ID at top -
MUST HAVE REGULATORY AGENCY APPROVAL
** CONTACT ADEQ IMMEDIATELY. **
*** MICROBIOLOGICAL GWR FECAL INDICATORS ANALYSIS ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
Sample
Total
3100
Analysis
Analysis Start
3014 3002 3028
1
Collection
Cl
Complete
Total Coliform
Specimen ID
2
2
Fecal Indicators
mg/L
Date
Time
P / A / NA
Method
Result
Date
Time
Date
Time
1 - Use only when method provides TC and E. coli results.
2 - See page 2 for Fecal Indicator Analyte Code and Method Citation. Check one box.
*** LABORATORY INFORMATION ***
>>> TO BE COMPLETED BY LABORATORY PERSONNEL <<<
[________________________]
Specimen Number
Comment [___________________________________________]
Lab ID Number [AZ________]
Lab Name [_______________________]
Phone Number [_________________]
Lab Contact, Printed Name [___________________]
Authorized Signature [________________________________]
PWS Notification Date [________________]
PWS Person Notified [_____________________________________]
Any positive routine or increased routine RTCR sample triggers the GWR and requires ADEQ notification:
ADEQ Notification Date [_______________]
ADEQ Person Notified [____________________________________]
PLEASE DO NOT SUBMIT
Submit completed form to:
MULTIPLE TIMES
EMAIL:
WQD_Compliance_Data@azdeq.gov
-or- MAIL: ADEQ Water Quality Compliance Data Unit (MC 5415B-1),
For questions call: (602) 771-9200
1110 W. Washington St., Phoenix, AZ 85007.
DWAR 1GR: Revised 12/2017