Social Survey Form

Field Area

: Lokasi 1 Lembah damai

Date

: 4 Sept 2016

Operating
Unit

FORM No.
1 Suspected

: HCT

Personel
Survey/
Assessor

: Aan

CPI persons

Nur Rahmat/M.Fadilah

(If present)
Not Exist

encroachment

Exist

*put all findings

in
table 'list of
encroachment
findings' in the
table
below

Occupied land

Direction (N/ E/ S/ W from facility)/

Remarks:

Site name:
GS

Canal
Wellpa
d
Pipelin
e
Other

X Filling Station

0772136/0063780

Interview questions:
What does the ownership status of the CPI
land which is occupied according to the
structure/ plants owner ?

Pribadi

How long the structure/ plants owner has

settled in the area in which they occupied?

48 Tahun

List of Encroachment
Findings
Coordinate &
Name of Site

Direction (N/ E/

Occupied

S/ W from
facility)

Lembah damai
RW 02

Length of

Land Status
according to

Occupation
occupants (e.g.
(month/
year)
certification)

48 tahun

Pribadi

Number of
Structure/
Plant (<10 or 10 50 or

(permanent or non-

>50)

permanent)/ Plant

>50

Type of Structure

Permanent

2 Nearby Community/
Residential Area
Not Exist

Exist

Nearby site/ facility:

Distance from facility (m)/

Remarks:

GS
Canal
Wellpad
Pipeline
Otherx
Approximate number of houses :

750 m
a.

< 10 houses

b.10-50
If houses found along c.> 50 houses
Canal,
observe
:
a.
waste dump
activity in the canal
from other than
b. household sewage discharge/
GS
toilet

c.washing and bathing

d.drainage from plantation
3 Groundwater
well

: Not Exist

Sumur
warga Exist
berada di tanah
milik
x
:

*put
all
CPI
findings in
table 'list of
groundwater
well findings'
in the
following page

Adjacent facility:
Depth:
Distance from
facility:

Adjacent site type:

3m

Gali
Type of well:

750 m

Coordinate & Direction (N/ E/ S/ W from

facility):
Use of groundwater by community:

x
x
x
x

Drinking
Toilet
Washing
Bathing
Oil sheen :
Odour :
Historical issue :

4 Flooding
Does flooding frequently occur in the
canal?
Flooding location :
facility:

Adjacent site
type:

Adjacent

Banyak terjadi pada saat hujan deras

When did the last time flood is

happen? How is the frequency?

50 cm

5 Other Industrial activity close to the area

Not exist
:
Exist
:
Distance (m)

Describe:

__________ m
Notes:

Measurements from wells taken from well head. Measurements for larger facilities taken from
boundary.

List of Groundwater Well

Findings
Name of Facility &
Site Type in
Depth (m)
Direction (N/ E/
adjacent
and
S/ W from
with groundwater
Type of Well
facility)
Sumur
gali
well

Coordinate &

Use of Groundwater

Oil sheen/ Odour/

Distance (m)

Well by Community

Historical Issue

250
3 mm
Tidak
Minum
Berminyak &
Cuci
Berbau
Mandi
Kakus

Sketch/ Map:

Remarks:

TANAH PT.CPI
PARIT

PERUMAHAN
WARGA

Photos :
Photo Number

Photo Description

GPS Point

Remarks