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Drinking Water Permits, Forms, and Templates

Find drinking water permit applications, reporting forms, and templates.
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Table of Contents

Autodialer & Contact Information

AutoDialer Registration (PDF 126.35 KB)
Contact Information / Notification Registration Form (PDF 18.82 KB)

Certified Operators Forms

Certified Operator Forms 

Consumer Confidence Reporting Forms & Templates

Consumer Confidence Reporting Forms & Templates 

Cross Connections Forms

Cross Connections Forms 

Distribution System Modifications Forms

WS 32: Distribution Modifications for Systems that serve more than 3,300 people 
WS 33: Distribution Modifications for Systems that serve 3,300 people or fewer 

Emergency Response Forms

Emergency Response Plan (ERP) Compliance Checklist (DOC 152 KB)
Emergency Response Checklist (DOCX 91.72 KB)
Emergency Response Report (After Action Report) (DOCX 581.34 KB)
Emergency Response (After Action Report) Sample Report (PDF 29.45 KB)
Water Treatment Chemical Feed System Control and Alarm Testing Log (DOC 199.5 KB)
Water Treatment Chemical Feed System Control and Alarm Testing Sample Log (PDF 30.57 KB)
Request for a Waiver from the Requirement for a Chemical Analyzer (DOC 109.5 KB)
Bulk Water Questionnaire (DOCX 57.46 KB)
Bulk Water Delivery Inspection Form (PDF 14.22 KB)
Emergency Certification of Public Water System Temporary Closure (Non-Operational Status) (DOCX 39.98 KB)

Form to be used when a Non-Community Public Water System (TNC, NTNC) has to temporarily close due to a declared State of Emergency.

Emergency Certification of Public Water System Temporary Closure (Non-Operational Status) (PDF 149.44 KB)

Form to be used when a Non-Community Public Water System (TNC, NTNC) has to temporarily close due to a declared State of Emergency.

Ground Water Rule Forms

Ground Water Rule Forms 

Ground Water Under the Direct Influence of Surface Water (GWUDI) Forms

Groundwater Under the Influence of Surface Water - Community Groundwater Exemption Application (DOCX 93.06 KB)

Laboratory Analytical Forms

MassDEP Identified Sampling Location Numbers (XLSX 3.68 MB)
Schools and Daycares Org Code List (XLS 3.05 MB)
Testing Requirements for Public Water Systems - Summary (PDF 364.89 KB)
Asbestos Report (DOC 122.5 KB)
Bacteriological Report (DOC 231 KB)
Bromate Report (DOC 94 KB)
Bromide Report (DOC 94 KB)
Chlorine/Chloramines - Monthly Report (DOC 131.5 KB)
Chlorite/Chlorine Dioxide (Daily Samples) Report (DOC 157.5 KB)
Chlorine Dioxide Distribution (3-Sample Set) Report (DOC 98 KB)
Chlorite Distribution (3-Sample Set) Report (DOC 99.5 KB)
Disinfection Byproducts Rule Compliance Report (XLSX 118.28 KB)
DBPR TT Compliance Report (DOC 121 KB)
Fluoride Monitoring & Reporting Forms 
Haloacetic Acids Report (DOC 130 KB)
Inorganic Contaminant Report (DOC 119.5 KB)
Lead and Copper Analysis Report (LCR-C) (DOC 156 KB)
Nitrate Report (DOC 118.5 KB)
Nitrite Report (DOC 118.5 KB)
Tetrachloroethylene (PCE) Report (DOC 121 KB)
Per- and Polyfluoroalkyl Substances (PFAS) Report (DOCX 59.48 KB)
Perchlorate Report (DOC 98 KB)
Radionuclide Report (DOC 116 KB)
Radionuclide Photon Activity Report (DOC 124 KB)
Uranium Guidance for Radionuclides Form 
Secondary Contaminant Report (DOC 149 KB)
Synthetic Organic Contaminant Report (DOC 263 KB)
Sodium Report (DOC 118.5 KB)
Total Organic Carbon (TOC) Report (DOC 110 KB)
Total Trihalomethanes Report (DOC 131 KB)
Volatile Organic Contaminant Report (DOC 288 KB)

Lead and Copper Forms & Templates

Lead and Copper Forms and Templates 

Monitoring Waiver Forms

Asbestos in Distribution System Exemption Form (DOC 200 KB)
Groundwater Under the Influence of Surface Water - Community Groundwater Exemption Application (DOCX 93.06 KB)
Monitoring Waiver Application for 2020-2022 Compliance Period 

Monthly and Daily Reporting Forms

Chemical Addition Report 
Chlorine/Chloramines - Monthly Report (DOC 131.5 KB)
SWTR A - Source Water Quality Conditions for Unfiltered Systems (DOC 151.5 KB)
SWTR A - Source Water Quality Conditions for Unfiltered Systems (XLS 261 KB)
SWTR B - CT Determination for Unfiltered Systems - Single Sampling Point (DOC 169.5 KB)
SWTR B - CT Determination for Unfiltered Systems - Single Sampling Point (XLS 262.5 KB)
SWTR C - CT Determination for Unfiltered Systems - More than One Sampling Point (DOC 153 KB)
SWTR C - CT Determination for Unfiltered Systems - More than One Sampling Point (XLS 256.5 KB)
SWTR E - Compliance Determination for Unfiltered Systems - Monthly Report (DOC 203.5 KB)
SWTR E - Compliance Determination for Unfiltered Systems - Monthly Report (XLS 406.5 KB)
SWTR F - Turbidity Data Sheet for Filtered Systems (DOC 134 KB)
SWTR F - Turbidity Data Sheet for Filtered Systems (XLS 253.5 KB)
SWTR G - Compliance Determination for Filtered Systems - Monthly Report (DOC 127 KB)
SWTR G -Compliance Determination for Filtered Systems - Monthly Report (XLS 253 KB)
SWTR H - CT Determination for Filtered Systems, More than 1 Disinfectant/Sampling Point (DOC 154 KB)
SWTR H - CT Determination for Filtered Systems, More than 1 Disinfectant/Sampling Point (XLS 257.5 KB)
SWTR I - CT Determination for Filtered Systems (DOC 171 KB)
SWTR I - CT Determination for Filtered Systems (XLS 263 KB)
SWTR J - Turbidity: Individual Filter Monitoring for Conventional or Direct Filtered Systems (DOC 233 KB)
SWTR J - Turbidity: Individual Filter Monitoring for Conventional or Direct Filtered Systems (XLS 380.5 KB)
PWS Monthly Storage Tank Inspection Log (DOC 157 KB)
Long Term 2 Enhanced Surface Water Treatment Rule (LT2 ESWTR) Forms 
Coliform Bacteria Level 1 Assessment 
Coliform Bacteria Level 2 Assessment 
UV Drinking Water Treatment Forms 

New Source Approval Forms

WS 13: Approval to Site a Source and Conduct a Pumping Test for a Source less than 70 Gallons per Minute 
WS 15: Approval of Pumping Test Report and to Construct a Source Less than 70 Gallons per Minute 
WS 17: Approval to Site a Source and Conduct a Pumping Test for a Source Greater Than 70 Gallons per Minute 
WS 19: Approval of Pumping Test Report for Source of 70 Gallons per Minute or Greater 
WS 20: Approval to Construct a Source of 70 Gallons per Minute or Greater 
WS 37: Approval of Transient Non-Community Source Less than 7 Gallons per Minute 

New Technology Approvals Forms

WS 11, 12: Minor, Major Technology Approval 
WS 27: New Technology - 3rd Party Approval 
WS 28: New Technology Vending Site/Source 
WS 31: New Technology - Vending Machines, POU/POE Devices 

Public Notification Forms & Templates

Public Notification Forms and Templates 

Public Water System Modifications Forms

WS 26: Sale or Acquisition of Land for Water Supply Purposes 
WS 36: Abandonment of Water Source 
Declassification/Reclassification of Public Water System (DOC 75.5 KB)

Source Water Protection Forms & Templates

Source Water Protection Forms & Templates 

Statistical Reporting Forms

Instructions for Electronic Annual Statistical Reporting (eASR) (PDF 1.37 MB)
Annual Statistical Reporting Worksheet - Confidently Estimated Use (XLS 25.5 KB)
Annual Statistical Reporting Worksheet - Estimating Population for RGPCD (MS Excel) (XLS 68.5 KB)
Annual Statistical Reporting via eDEP Online Filing 

Surveys and Questionnaires

2019-2020 Mercury Questionnaire (DOC 177.5 KB)

Questionnaire conducted approximately every five years to determine the extent of the use of mercury-containing products at public water systems.

Underground Injection Control Forms

Underground Injection Control Forms 
Permit Requirements for Hydrostatic Water Testing of New Pipelines (PDF 48.87 KB)

Vending Machines Forms

WS 30: Site Vending Machine Approval 
WS 35: Permit to Install Multiple Vending Machines 
WS 28: New Technology Vending Site/Source 
WS 31: New Technology - Vending Machines, POU/POE Devices 

Water Management Act (WMA)

WMA Reporting and Forms 
WMA Permits and Permit Renewals 

Water Treatment Plant Forms

WS 21: Approval to Conduct Pilot Study 
WS 22: Approval of Pilot Study Report 
WS 23, 24: Approval to Construct a Water Treatment Facility 
WS 25: Approval of Treatment Facility Modification 
WS 29: Chemical Addition Retrofit of Water Systems Serving More than 3,300 People 
WS 34: Water Treatment - Chemical Addition Retrofit of Water Systems Serving Less than 3,300 People 
Water Supply Facility Checklist for Potassium Hydroxide (KOH) or Sodium Hydroxide (NaOH) for Permit Review/Approval (DOC 563 KB)
Water Supply Facility Checklist for Hypochlorination Using Sodium Hypochlorite (NaOCl) or Calcium Hypochlorite (Ca(OCl)2) for Permit Review/Approval (DOC 744.5 KB)
Water Supply Facility Checklist for Chlorination Using Cl2 Gas for Permit Review/Approval (DOC 589.5 KB)
Water Supply Facility Checklist for Fluoridation Using Sodium Fluoride Saturator for Permit Review/Approval (DOC 511 KB)
Water Supply Facility Checklist for Hydrofluosilicic or Fluorosilicic Acid (H2SiF6) for Permit Review/Approval (DOC 519.5 KB)
Water Supply Facility Checklist for Various Forms of Phosphate Compounds Used for Corrosion Control and Sequestering for Permit Review/Approval (DOC 493.5 KB)
Water Supply Facility Checklist for Ultraviolet (UV) Disinfection for Permit Review/Approval (DOC 488.5 KB)
Water Supply Facility Checklist for Chloramine Formation Using an Ammonia Compound for Permit Review/Approval (DOC 744 KB)
Water Supply Facility Checklist for Disinfection Using On Site Generated Chlorine Dioxide (ClO2) for Permit Review/Approval (DOC 749.5 KB)

Well Drillers Forms

Well Completion Report Correction & Change Request (DOC 67 KB)
Well Completion Report Correction & Change Request (PDF 100.93 KB)
General Well Report (eDEP Online Filing Recommended) (PDF 186.18 KB)
Monitoring Well Report (eDEP Online Filing Recommended) (PDF 187.17 KB)
Geothermal Closed-Loop Well Report (eDEP Online Filing Recommended) (PDF 208.96 KB)
Decommissioned Well Report (eDEP Online Filing Recommended) (PDF 140.71 KB)

WIIN Act

WIIN Template A (DOCX 324.22 KB)

For households where the public water system's 90th percentile level in their most recent sampling round is below the action level and the household's lead sample result is greater than 15 ppb.

WIIN Template B (DOCX 325.11 KB)

For households where the public water system's 90th percentile level in their most recent sampling round and the household's lead sample results are greater then 15 ppb.

WIIN Confirmation Form (Lead-WINN-C) (DOCX 56.79 KB)

The Confirmation Form is for public water system (PWS) to confirm distribution of the required information to EPA, MassDEP, and the Local Board of Health.

Zone II Determinations Forms

WS 07: Zone II Pumping Test 
WS 08: Zone II Approval 
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