DNR Form 542-3104 "Groundwater Monthly Operation Report" - Iowa

What Is DNR Form 542-3104?

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

Form Details:

  • Released on October 1, 2009;
  • The latest edition provided by the Iowa Department of Natural Resources;
  • 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 DNR Form 542-3104 by clicking the link below or browse more documents and templates provided by the Iowa Department of Natural Resources.

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Download DNR Form 542-3104 "Groundwater Monthly Operation Report" - Iowa

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GROUNDWATER MONTHLY OPERATION REPORT
IOWA DNR WATER SUPPLY
Page 1 of 2
Facility Name:
PWSID Number:
Treatment Plant #:
S/EP #:
Month:
Year:
Pumpage
Chlorine
Fluoride
Other
Quantity
to
Free Chlorine (mg/L)
Total Chlorine (mg/L)
Quantity
Used
D
D
Used
system
At Plant
In System
At Plant
In System
lbs.
lbs.
a
in
Raw
S/EP
a
or
or
(mg/L)
(mg/L)
y
gals.
y
# of
# of
# of
# of
thousands
gals.
Avg.
Avg.
Avg.
Avg.
(circle
Tests
Tests
Tests
Tests
(circle
of
one)
one)
gallons
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
23
23
24
24
25
25
26
26
27
27
28
28
29
29
30
30
31
31
Total
Total
Avg.
Avg.
Max.
Max.
Min.
Min.
%
Percentage of available chlorine in compound applied:
I certify that I am familiar with the information contained in this report and that the information is true, complete, and accurate.
DRC Operator or Designee's Signature:
Certificate #:
Grade:
Date:
Oct. 2009
IDNR Form #: 542-3104
Print Form
GROUNDWATER MONTHLY OPERATION REPORT
IOWA DNR WATER SUPPLY
Page 1 of 2
Facility Name:
PWSID Number:
Treatment Plant #:
S/EP #:
Month:
Year:
Pumpage
Chlorine
Fluoride
Other
Quantity
to
Free Chlorine (mg/L)
Total Chlorine (mg/L)
Quantity
Used
D
D
Used
system
At Plant
In System
At Plant
In System
lbs.
lbs.
a
in
Raw
S/EP
a
or
or
(mg/L)
(mg/L)
y
gals.
y
# of
# of
# of
# of
thousands
gals.
Avg.
Avg.
Avg.
Avg.
(circle
Tests
Tests
Tests
Tests
(circle
of
one)
one)
gallons
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
23
23
24
24
25
25
26
26
27
27
28
28
29
29
30
30
31
31
Total
Total
Avg.
Avg.
Max.
Max.
Min.
Min.
%
Percentage of available chlorine in compound applied:
I certify that I am familiar with the information contained in this report and that the information is true, complete, and accurate.
DRC Operator or Designee's Signature:
Certificate #:
Grade:
Date:
Oct. 2009
IDNR Form #: 542-3104
GROUNDWATER MONTHLY OPERATION REPORT
IOWA DNR WATER SUPPLY SECTION
Page 2 of 2
Facility Name:
PWSID Number:
Treatment Plant #:
S/EP #:
Month:
Year:
Maximum Residual Disinfectant Level (MRDL)
Calculation
D
Number of
Running
a
Actual
Samples
Monthly
Annual
Month/
y
Used in
Average
Average
Year
Calc.
(RAA)*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Calculation of maximum disinfectant residual is based on
the monthly average of the Total chlorine residual
16
measured at the same time compliance bacterial samples
17
are collected (includes Repeat/Check samples but
18
excludes Specials). *Should not exceed 4.0 mg/L.
19
The RAA must be calculated at the end of each calendar
20
quarter and include the previous 12 months.
21
22
23
Water Levels (ft.)
24
Date:
25
Pumping
Well #
Static
26
27
28
29
30
31
Total
Avg.
Max.
Min.
Comments:
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