Please return completed form to: Developer Services Dee Valley Waterplc Packsaddle Wrexham Road Rhostyllen LL14 4EH E-mail address: developer.services@deevalleygroup.com 1. Developer Details Name: Company (if applicable): Address: Tel No (including dialling code): Fax No (including dialling code): E-mail address: Post Code: 2. Site Location Details Development Details Address: Post Code: Residential Commercial Mixed 2.1 Is the new water supply required for a development on a brownfield siteyes No IfYes go to section 3.1If No, please provide details below of previous use of site and adjacent sites and then go to 2.2
2.2 Has the site or any adjacent sites or other land through which the pipeline is proposed to be laid potentially been affected by contamination? Yes No If Yes, go to 3.1. If No, go to 5.1 3. Site Assessment 3.1 Has the Preliminary Risk Assessment (PRA) determined the need for a site investigation? Yes No IfYes, go to 4.1. If No, go to 5.1 4. Site Investigation 4.1 The data from the site investigation should be used to populate the pipe selection risk assessment summary in Table 1 below. 4.2 Date when site investigation was carried out 4.3 How many metres below ground level was ground water encountered? 4.4 Ensure all intrusive site investigation details are attached to this assessment and then go to 5.1 5. Site Remediation 5.1 Has any site remediation (including changes in site levels) been undertaken? Yes No If Yes, go to 5.2. If No, go to 5.3 5.2 Has Table 1 and 2 been completed using data after remediation? Yes No IfYes, then provide details of remediation and go to 5.3. If No, then a new site investigation is required and table 1 and 2 should be repopulated. Then go to 5.3. 5.3 Is any site remediation planned for the site? Yes No If Yes, then provide details of further remediation and go to 6.1. If No, then go to 6.1. 6. Final Use of Site 6.1 Is there any storage of chemicals (including fuels) to be stored on the site that may affect the proposed pipe selection? Yes No IfYes, then provide details of chemicals and go to 6.2. If No, then go to 6.2
6.2 Are there any further contamination risks that may affect pipe selection? Yes No IfYes, then provide details of chemicals and go to 6.3. If No, then go to 6.3 6.3 What pipe materials are proposed by the developer?
Analysis only required where identified Analysis required where preliminary risk assessment has identified land potentially affected by contamination PIPELINE RISK ASSESSMENT Test Total VOCs 0.5 Pass Total BTEX & MTBE 0.1 Pass Total SVOC (excluding PAHs and 2 Pass those substances marked with an * EC5-EC10 aliphatic and aromatic 2 Pass hydrocarbons EC10-EC16 aliphatic and aromatic 10 Pass hydrocarbons EC16-EC40 aliphatic and aromatic 500 Pass hydrocarbons Phenols* (from SVOC analysis) 2 Pass Cresols and chlorinated phenols* 2 Pass (from SVOC analysis) Ethers* 0.5 Pass Nitrobenzene* 0.5 Pass Ketones* 0.5 Pass Aldehydes* 0.5 Pass Amines Fail Pass Table 1 Pipe Selection Risk Assessment Summary All concentrations should be in mg/kg PE Threshold Metal pipes/barrier pipe Laboratory detection limit Testing UKAS accredited Y/N Maximum concentration at proposed pipeline depth (see Note [2]) Maximum site concentration (see Note [3]) Locations and depths where concentrations exceed proposed pipeline threshold Corrosive (conductivity, redox and ph) See Note [1] Pass See Note [1] Note [1] For wrapped steel, corrosive if ph <7 and conductivity >400µS/cm. For wrapped ductile iron, corrosive if ph <5, Eh not neutral and conductivity >400µS/cm. For copper, corrosive if ph <5 or >8 and Eh positive.note [2] Water pipes are normally laid at 0.75-1.35m below finished ground level. Note [3] Also state if liquid free product is present in soil or groundwater.
7. Health and Safety Assessment 7.1 The data from the site investigation should be used to populate table 2 below to assess the health and safety risks to Dee Valley Water staff. Table 2 CLEA Health and Safety Summary Contaminant Soil guideline value mg/kg Arsenic 32 Nickel 130 Mercury 170 Selenium 35 Cadmium 10 Benzene 0.33 Toluene 610 Ethylbenzene 350 Xylene 230 Phenol 420 Laboratory detection limit mg/kg Testing UKAS accredited Y/N Maximum site concentration mg/kg Locations and depths where concentrations exceed soil guideline value 7.2 Are there any other soil properties that could constitute a health and safety risk? 7.3 Do soil results meet the guideline values given in Table 2. Yes No IfYes, then go to 8.1. If No, then undertake remediation and go to 5.1 8. Any Other Information 8.1 Please provide any other information that you feel may assist Dee Valley Water in providing you with a quotation. 9. Applicant Checklist 9.1 Have all sections of the form been completed? Yes No 9.2 Has a site layout plan been enclosed? Yes No 9.3 Has all relevant information been provided? Yes No
10. Risk Assessor 10.1 Name and relevant qualifications of person directing the risk assessment for water pipes formand date risk assessment performed: 10.2 Name and address of risk assessor s company: 11. Declaration I confirm that I have completed this form and provided supporting information within the Site Assessment Report (SAR) in accordance with UKWIR Guidance for the Selection of Water Pipes to be used in Brownfield Sites and Dee Valley Water s Contaminated Land Policy and Guidance document. I also confirm that, if any further site investigation is needed and carried out, I will be required to submit an additional Pipeline Risk Assessment with the relevant supporting documentation. I understand that failure to supply any of the required information may result in a delay to my application being processed. Signature: Company Name: Print Name: Date: General Notes: Charges will apply for work undertaken and the information provided. These charges are detailed in the Dee Valley WaterCharges Scheme.
The information requested on this form is required for Dee Valley Water to provide you with an accurate quotation. Missing or misleading information could lead to additional costs and delays at a later date. Before completing the application form you should read the Conditions for New Water Connections