Form DW-1 Construction Application for Drinking Water Distribution - Kentucky

Form DW-1 is a Kentucky Energy and Environment Cabinet form also known as the "Construction Application For Drinking Water Distribution". The latest edition of the form was released in August 30, 2010 and is available for digital filing.

Download a PDF version of the Form DW-1 down below or find it on Kentucky Energy and Environment Cabinet Forms website.

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Form DW-1
Commonwealth of Kentucky
Energy and Environment Cabinet
Division of Water
Construction Application
For Drinking Water Distribution
See the instructions for more information about selected portions of this application.
Questions on completing this application? Contact the Water Infrastructure Branch at 502/564-3410, by e-mail at
WIBEngineering@ky.gov
or visit our website at
http://water.ky.gov
for more information.
I.
Construction Project Information
Project Name:
Project County:
Estimated Project Cost: $
Project Latitude/Longitude (DMS):
Is this a federally funded project:
DWSRF
SPAP
Other:
If yes, has an Environmental Information Document been reviewed and approved?
If the project has been submitted to the State Clearinghouse for review, provide the SAI number:
Identify all other funding sources:
Does the project contain any of the following:
Booster Pump Stations
Water Storage Tanks
Waterlines
Waterline Material
Waterline Size
Linear Feet
Provide a DETAILED description of work to be performed for this project. Attach additional sheets as necessary:
Page 1 of 4 DOW-WIB 8/30/2010
Form DW-1
Commonwealth of Kentucky
Energy and Environment Cabinet
Division of Water
Construction Application
For Drinking Water Distribution
See the instructions for more information about selected portions of this application.
Questions on completing this application? Contact the Water Infrastructure Branch at 502/564-3410, by e-mail at
WIBEngineering@ky.gov
or visit our website at
http://water.ky.gov
for more information.
I.
Construction Project Information
Project Name:
Project County:
Estimated Project Cost: $
Project Latitude/Longitude (DMS):
Is this a federally funded project:
DWSRF
SPAP
Other:
If yes, has an Environmental Information Document been reviewed and approved?
If the project has been submitted to the State Clearinghouse for review, provide the SAI number:
Identify all other funding sources:
Does the project contain any of the following:
Booster Pump Stations
Water Storage Tanks
Waterlines
Waterline Material
Waterline Size
Linear Feet
Provide a DETAILED description of work to be performed for this project. Attach additional sheets as necessary:
Page 1 of 4 DOW-WIB 8/30/2010
Identify how the sanitary wastewater produced as a result of this project will be handled:
Sanitary Sewer
WWTP:
Septic Tank
Other:
II.
Utility Information
Utility Name:
PWSID:
Street Address:
County:
City, State, Zip:
Phone #:
Fax #:
Email:
If another utility will serve any portion of the proposed project, provide the name and PWSID No.
Utility Name:
PWSID No.
If the utility serving the project purchases water from another utility, provide the name and PWSID No. and purchase contract amount.
Utility Name:
PWSID No.
Purchase Contract Amount:
Utility Name:
PWSID No.
Purchase Contract Amount:
Utility Name:
PWSID No.
Purchase Contract Amount:
Is the system currently under any type of waterline or sewer sanctions?
If yes, submit an exception request and attach supporting documentation to justify its approval.
III.
Design Considerations
A. Plans and Specifications
Plans and specifications shall comply with 401 KAR 8:100 and “Recommended Standards for Water Works” 2007
Edition (Ten States’ Standards). All plans must contain a P.E. seal, signature and date of signature with at least one set
having an original seal and signature. Provide detailed plans (no larger than 24” X 36”) which must comply with 401 KAR
8:100. See the instructions for additional details.
B. Design Engineer
Name:
Firm:
Street Address:
City, State, Zip:
Phone #:
Fax #:
Email:
Design Capacities
Identify the number of new connections and the projected average daily demand:
Identify the number of existing residents, and their projected water demand, that may be served as a result of this project:
Identify the number of connections in the service area:
Page 2 of 4 DOW-WIB 8/30/2010
Other Information to be Submitted with the Project
1.
Provide a copy of the U.S.G.S. 7 ½ minute topographic map or a detailed vicinity map with the location(s) of the
proposed project.
2.
If the project includes a new or upgraded pump station(s), provide the pump sizing calculations and the proposed
pump’s characteristics curve along with the efficiency, horsepower and NPSHR data. Also, identify each pump
station’s locations coordinates (DMS).
3.
If the project proposes the addition of storage tanks, provide engineering calculations which demonstrates a
complete fill and drain cycle every 72 hours. Also, identify each storage tank’s location coordinates (DMS).
4.
Provide engineering calculations or an electronic model demonstrating the availability of 30 psig in the waterline
under peak demand conditions.
5.
Provide engineering calculations or an electronic model that demonstrates if the proposed waterlines are capable
of a 2.5 ft/sec flow velocity and show associated residual system pressures.
6.
Provide a signed letter of acceptance from the utility, which states that the utility has reviewed and approved the
plans and specifications and agrees to serve the proposed project upon completion. If another utility will own,
operate and maintain any portion of this project provide an acceptance letter from that utility as well.
7.
If the utility is a purchaser and the project demand is over 10,000 gallons per day or the utility has exceeded 85%
of its purchase contract, provide a valid acceptance letter from the seller.
8.
If the project will provide water service to existing residences, provide the names and addresses of all existing
residences to be served by the project, if known.
9.
If the project is funded by a State Revolving Fund Loan (SRF) provide a completed SRF Plans and Specifications
Checklist along with 1 complete printed copy of the project specifications.
IV.
Environmental Benefits
Identify the environmental benefit(s) of the project by checking all that apply.
Construction of new waterlines serving existing residences previously without public water.
Modifies/upgrades existing waterlines:
Inadequately sized waterlines.
Leaks, breaks, restrictive flow.
Replaces lead, copper or asbestos cement waterlines.
Other:
Provides fire protection.
Replaces tanks/pumps due to age/condition.
Installation of high efficiency/energy saving pumps.
Other. Provide a brief description in the space below.
Page 3 of 4 DOW-WIB 8/30/2010
V.
Fees
Check or money order must be made payable to “Kentucky State Treasurer” for the total amount. Fees do not apply to projects
FUNDED by a municipality, water district, or other publicly owned utility.
Project Category:
Total Amount: $
Page 4 of 4 DOW-WIB 8/30/2010

Download Form DW-1 Construction Application for Drinking Water Distribution - Kentucky

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