Community Borehole

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STRENGTHENING COMMUNITIES UNITED KINGDOM
COMMUNITY BOREHOLE PROJECT

Community Contact Person
Name*

First NameLast Name
Position / Title*

Village Head / Community HeadElder-in-CouncilTraditional RulerPalace Secretary / ClerkCouncil of Elders MemberWomen LeaderYouth LeaderOther
Please specify.....
Phone Number*

country CodePhone Number
Email (if available)
example@example.com
Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Community Details
Name of Community / Village / Area:*

Street Address Line 2

Local Government Area (LGA):State

Zip CodeCountry
Borehole Need Assessment
Is there currently a source of clean water in the community?*

YesNo
If yes, what is the condition of the existing source(s)?*

FunctionalPartially FunctionalNon-FunctionalContaminated
Estimated number of people who will benefit from the borehole: ___________
Proposed Borehole Location
Proposed Site (landmark, address, or GPS coordinates if available*

Street Address Line 2

CityState / Province

Postal / Zip Code
Who owns the land?*

CommunityIndividualGovernment
If Individual please provide the name and contact of the individual: ___________
Is the land donated for the borehole project?*

YesNo
Community Contribution & Support
Will the community contribute to the project (e.g., labor, materials, security)?*

YesNo
Is there a designated committee or person to manage the borehole after installation?*

YesNo
If yes, name of committee or person: ___________________________
Declaration & Consent
Please read the following statements carefully and tick the boxes to indicate your agreement.

I confirm that the information provided is accurate to the best of my knowledge.I understand that this form is for assessment and planning purposes only and does not guarantee immediate borehole construction.I understand that any false information may lead to the rejection of this project
Should be Empty:

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