Run Water Main Disinfection and Bacteriological Clearance Record — Free

Inspection Details

Project / main identification recorded

Record the project name, main segment ID, location, size, material, and whether this is a new installation or repair.

Inspection date and time recorded critical (required)

Document when the disinfection and clearance inspection was completed.

Inspector and competent person identified

Record the inspector name, contractor/utility representative, and competent person overseeing the work.

Pre-Disinfection Preparation

Main isolated from service and work area secured critical (required)

Verify the main is isolated, valves are controlled, and the work zone is secured before cleaning or disinfection begins.

Yes No N/A

Pipe interior cleaned of debris and visible contamination critical (required)

Confirm the main was cleaned of dirt, scale, construction debris, and other visible contamination before disinfection.

Yes No N/A

Photo evidence (optional)

Temporary fittings, hoses, and equipment approved for potable water use critical (required)

Verify any hoses, pumps, fittings, and appurtenances used during flushing or chlorination are suitable for potable water service.

Yes No N/A

Backflow prevention or cross-connection controls in place critical (required)

Confirm controls are in place to prevent contamination or unintended backflow during the work.

Yes No N/A

Disinfection and Contact Time

Disinfectant type and dosage documented critical (required)

Record the disinfectant used, target dosage, and method of application.

Initial chlorine residual measured critical (required)

Record the measured residual at the start of the contact period.

Note (optional)

Required contact time achieved critical (required)

Record the elapsed contact time before flushing or sampling.

Residual chlorine maintained throughout contact period critical (required)

Verify the disinfectant residual remained at or above the required level for the full contact period.

Yes No N/A

Flushing and Sampling

Main flushed until water ran clear critical (required)

Confirm flushing was completed until turbidity, discoloration, and debris were removed to the extent required by the procedure.

Yes No N/A

Photo evidence (optional)

Flushing volume or duration recorded

Record the flushing volume or duration used to clear the main.

Note (optional)

Bacteriological samples collected from approved locations critical (required)

Verify samples were collected from the required points using approved sampling procedures.

Yes No N/A

Sample collection date and chain-of-custody documented critical (required)

Record when samples were collected and ensure sample handling documentation is complete.

Note (optional)

Bacteriological Results and Clearance

All bacteriological sample results satisfactory critical (required)

Confirm all required samples were absent of contamination and met the clearance criteria before return to service.

Yes No N/A

Lab report attached critical (required)

Attach the laboratory report or clearance documentation for the collected samples.

Main approved for return to service critical (required)

Document final approval to place the main back into service after satisfactory results and required corrective steps.

Yes No N/A

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Run: Water Main Disinfection and Bacteriological Clearance Record

Inspection Details

Pre-Disinfection Preparation

Disinfection and Contact Time

Flushing and Sampling

Bacteriological Results and Clearance

Get your results