GENERAL INFORMATION

Name of responsible authority …………………………………………

Province …………………………………….

District …………………………………………

Town/Village/Resettlement ……………………………….

Locality ………………………………..

Geographical coordinates
Latitude……………………………………………..

Longitute……………………………………………

Water Sampling
Form of source…………………………

Season………………………………..

Date of sampling……………………………… Time………………………….

Date sent…………………………….. Time

ANALYSIS OF RESULTS

Feacal coaliforms ………………………CFU/100ml

Residual Chlorine…………………………..mg/litre

Ph………………………………….

Turbidity………………………

Name of EHT….........................................................
 BOREHOLE INSPECTION FORM
Water Point Name: .........................................
GPS Coordinates: .........................................
Date: .........................................
WPC Member present: ...........................................

RISK If answer is
SPECIFIC DIAGNOSTIC INFORMATION FOR ASSESSMENT YES,
YES NO Add points

1 Is there a latrine within 10m of the hand-pump?

2 Is the latrine on higher ground than the hand-pump?

3 Is there any source of pollution within 10m of the hand-pump [e.g.

rubbish, animal excreta, and surface water]?
4 Is the drainage poor, causing stagnant water within 2m of the hand-
pump?
5 Is the hand-pump drainage channel faulty? [is it broken, permitting
ponding]
6 Is the fencing around the hand-pump inadequate, allowing animals
in?
7 Is the concrete floor less than 1m wide all around the hand-pump?

8 Is there any ponding on the concrete floor around the hand-pump?

9 Are there cracks in the concrete floor around the hand pump-which
would permit water to enter the well?
10 Is the hand-pump loose at the point of attachment to the base so that
water could enter the casing?
TOTAL SCORE

KEY TO RISK SCORE:

9TO20 Very high-condemn and discontinue use
6to8 High-treat
3to5 Medium-may be subjected to treatment
0to2 Very low-can be used

Recommendations
...............................................................................................................
...............................................................
Name of Inspector ......................................................…Designation EHT