Guidance For Providing Safe Drinking Water in Areas of Federal Jurisdiction - Version 1

Appendix 5: Water Main Break Report (Sample)

General

Date and time break reported:

Time when water was shut off:

Time when water was turned on :

Properties affected :

Air temperature:

Repair by :

Property damage:

Location

Nearest property address:

Distance from nearest property line:

Distance from nearest intersection :

Northing and easting :

Isolation valves operated:

Physical Data

Pipe diameter:

Pipe material:

Year of installation :

Pipe wall thickness or pipe class:

Type of lining:

Type of joint:

Type of water service :

Normal operating pressure:

Under boulevard or road :

Depth of cover :

Depth of frost :

Type of native soil :

Type of backfill :

Soil resistivity:

Soil sample collected (Yes / No) :

Pipe sample collected (Yes / No) :

Type of Failure

Circumferential break
Longitudinal break
Split bell
Corrosion pit hole
Leaking joint
Leaking valve
Leaking service connection

Probable Cause of Failure

Corrosion
Ground frost
Joint failure
Disturbance (third party)
High pressure
Frozen pipe

Type of Repair

Repair clamp
Replace pipe section
Replace valve
Replace service connection
Anode installed
Repair joint