Free DBB-005, Application for Expanded Acres/ Change of Use/Relocation/ Additional Commingling Info. - Colorado

DBB-005 (6/2006)

COLORADO GROUND WATER COMMISSION Room 818 Centennial Building, 1313 Sherman Street Denver, CO 80203 Part I - Basic Information and Well Data

Application must be complete where applicable. Type or print in BLACK INK. No overstrikes or erasures unless initialed.

APPLICATION FOR A CHANGE OF WATER RIGHT FOR PERMIT NO._________________:



(Check one) Expanded Irrigated Acres (fill out application completely) Change of Use (omit nos. 5 and 7 in Part I) List uses:____________________________________________________________________. Relocation (omit no. 5 in Part I). Relocation means to redrill an existing well at a location in excess of 300 feet and less than 1/2 mile from the original permitted well location. Indicate the proposed well location: _______1/4 _______1/4 of Section _______, Township _______ ___________, Range _______ West, 6th P.M., _________ feet from the N/S Section line, __________ feet from the E/W Section line. Additional information for commingling application (omit no. 5 in Part I).





Include a $100.00 filing fee for each permit involved. Make the check payable to the State Engineer's office. If the well operates under two permits, indicate both permit numbers. If multiple wells are involved, complete a separate form for each well. 1. Is this well within a Ground Water Management District? Yes_____ No______ Which District? ___________________________________ Ground Water Management District. 2. Name of designated ground water basin: _____________________________________________ 3. Application is hereby made for the above indicated change of water right for the existing well indicated above located in ____________________________ County in the _______1/4 _______1/4 of Section ___________, Township ________________, Range _________________, 6th Principal Meridian. 4. Name _____________________________________ Address ___________________________________ City _______________________________________ State ________________ Zip Code _____________ Telephone: _________________________________ Permitted No. of Acres _______________ Permitted Acre-Feet _________________ Actual Well Location: _________ ft. from _________ section line _________ ft. from _________ section line

5. As current owner(s) of the well described above, I (we) request an increase in the permitted number of acres which can be irrigated to a total of __________ acres, described as follows: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Div. Co. WD FOR OFFICE USE ONLY Basin MD Use Receipt No._______

6. DIAGRAM OF PRESENTLY IRRIGATED ACRES AND WELL LOCATION

7. DIAGRAM OF PROPOSED IRRIGATED ACRES AND WELL LOCATION

1 mile, 5280 feet

1 mile, 5280 feet

North Section Line

North Section Line

West Section Line

West Section Line

East Section Line

N

East Section Line

N

South Section Line

South Section Line

Please locate the well in the middle section of each diagram. If a larger area is needed, you may submit sketches on a separate sheets

The scale of each diagram is 1 inch = 4000 feet. Each small square represents 40 acres

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Part I (cont'd.) 8. Provide a simple diagram of your irrigation system. Show total system from pump to discharge, other pumps in the same well, and electrical system including other devices on the same meter. Show where test meter and pressure gauge were placed and how system was modified to perform test. Show measurements. In addition to sketch, an attached Polaroid picture is recommended. Include a brief explanation of your operating procedure. Example of an irrigation system diagram:

Valve Well

To ditch To sprinkler

Meter Pressure Gage

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Part II - Pump Test, Power and Crop Data (FILL OUT PART II COMPLETELY. AN INCOMPLETE APPLICATION WILL BE RETURNED) It is the applicant's responsibility to provide sufficient information for the staff to determine the extent of historic withdrawals. TABLE A ­ POWER CONSUMPTION COEFFICIENT RATING FOR ELECTRIC PUMPS (FOR ALL OTHER PUMPS CONTACT OFFICE) This test is to determine the overall efficiency of the well (power consumption coefficient). All values, including pressure and input horsepower, must be measured on site. Note that well tests are performed several ways to obtain a variety of information. Providing a copy of this form to whomever does the test may help insure that the correct procedure is followed. The test should be conducted late in the irrigation season, during August thru October, when the ground water table is typically lower. Additional tests may be submitted at the applicant's option. This test must be conducted with the system under full operating conditions. If the well drives a sprinkler, the sprinkler must be connected and operating. Such a test must be conducted by a certified well tester as determined by the State of Colorado. A list of certified well testers is available on line at www.water.state.co.us. The requirement for the test may be waived where other supportive data on yield, water level, sprinkler operating pressures, and efficiency justify. WELL LOCATION AND INFORMATION: Structure ID number: Well Permit No.:

Information below required only when the well does not have a Structure ID tag or the above information is incomplete. ¼, ¼, Section , Township , , Range , West, PM

ELECTRICAL SUPPLIER: Power Company Name: Power Company Meter No.: Account No.: Manufacturer's Serial No.: Yes Yes Yes No No No (kWh) Multiplier: Potential Transformer Factor (PT): Current Transformer Factor (CT): Kh factor: None None 2.5:1(2.5) 200:5(40) Number of Rotating Digits: 2.4:1(2.4) 400:5(80) Other (specify) 800:5(160) Other (specify)

Is the electric meter owned and read by the electric company? Are other devices served by the electric meter (compound system)? If yes, describe If yes, were all devices operating during test?

Electric meter reading at time of test (include all rotating digits including leading zeros):

Pkh = Kh x PT x CT = -4-

TABLE A ­ POWER CONSUMPTION COEFFICIENT RATING (CONTINUED) PUMP INFORMATION: Pump type (turbine, centrifugal, submersible, etc.): Discharge pipe diameter (outside diameter): Describe all possible discharges from the well: inches Motor Horsepower:

TEST DATA: Date of Test: Time of Test: hours feet

How long has the pump been running prior to test? tic water level below centerline of discharge (required only if pump is not running upon arrival):

Pumping level below centerline of discharge (must show that drawdown has not changed more than 10% in last hour*) Time Pumping level in ft. Time Pumping level in ft.

Discharge pressure at well head (must show pressure has not changed more than 10% in last hour*, not required on low pressure system, i.e., open discharge, gated pipe, etc.) Time Pressure in P.S.I. Time Pressure in P.S.I.

Time

Total Dynamic Head in ft.

Time

Total Dynamic Head in ft.

COMMENTS on above pumping/pressure tests:

* The PCC test must be conducted only after the system has stabilized; both drawdown (pumping level minus static water level) and operating pressure have not changed more than 10% in the last hour. For alluvial and other shallow wells which are running for at least 2 hours prior to arrival, stabilization may be demonstrated by a determination that the change in pumping level does not exceed 1 foot per hour. This must be measured over at least one 15 minute interval.

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TABLE A ­ POWER CONSUMPTION COEFFICIENT RATING (CONTINUED) DETERMINATION OF STABILIZED PUMPING RATE: Test Meter Manufacturer: Serial No.: Date of Last Calibration:

Calculations, notes, times, etc., used to determine Q (in G.P.M.):

Q= DETERMINATION OF POWER DEMAND: (MINIMUM OF THREE TESTS) Disk Revolutions: Seconds Rate (Rev/Sec)

G.P.M.

Average Rate: Power demand, P = Average Rate x 3.6 x Pkh = CALCULATION OF POWER CONSUMPTION COEFFICIENT: PCC =

K.W.

5433xP = Q

K.W.H./A.F.

Methods of calculating power consumption coefficient are specified in U.S.G.S. Water Resources Investigation Report (89-4107) , state that I am currently a TESTER VERIFICATION: I, person approved by the State Engineer to conduct well tests. I have conducted a power consumption coefficient rating of the above described well. Based on the information contained on this form, I represent this test as being an accurate method of determining water use from the well. I understand that falsifying a power consumption coefficient rating can subject me to a fine of up to $500.00. SIGNATURE OF TESTER: DATE:

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TABLE B ­ POWER CONSUMPTION

Verification, such as billing statements or a signed document from the power company, must be provided. Complete this table for at least the most recent ten consecutive years. Where
readings from a totalizing flow meter are available, they may be substituted for the power data. Please submit any available information on depth to water while pumping. IMPORTANT: Indicate system operating pressure for sprinkler systems and any changes in this or irrigation equipment, including pumps and motors. Use a supplemental sheet if required.

Electric

Natural Gas Thousand Cu. Ft. (MCF)

Diesel or Gasoline (indicate which type of fuel used each year) Gallons H.P.

Year

KWH

Billing H.P.

H.P.

Operating pressure, depth to water, changes in pumping equip., irrigation equipment, flow meter readings, etc.

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TABLE C ­ HISTORIC CROP PRACTICE Data in this table is supplemental to the prior two tables. The table should be completed as well as available data allows. The amount of detail and length of record required depends upon the information contained in the previous tables. FSA crop acreage reports (Form OMB No. 0560) and accompanying aerial

photos must be provided for all years available.
List all crops grown each year since the well was originally put to use, the acres of each crop and the method of irrigation (flood or sprinkler). If a full history of cropping cannot be provided due to change in ownership or missing records, the ten most recent years of records should be furnished. Each year's data must contain complete information on crops, acres in each crop, and irrigation method. Use additional sheets if necessary. Where the record is dependent upon the testimony of neighbors or former owners or operators, affidavits must be attached. For sprinkler irrigation, please indicate operating pressure of the sprinkler system. (CROPS D,E & F FOLLOWING PAGE) Crop A Year Crop Acres Irrig. Method Crop Crop B Acres Irrig. Method Crop Crop C Acres Irrig. Method

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TABLE C - HISTORIC CROP PRACTICE (CONTINUED) Crop D Year Crop Acres Irrig. Method Crop Crop E Acres Irrig. Method Crop Crop F Acres Irrig. Method

I hereby affirm that I have read and understand the above application and that the information I have provided is true and correct. [Pursuant to Section 24-4-104(13)(a) C.R.S., the making of false statements herein constitutes perjury in the second degree and is punishable as a Class 1 misdemeanor.] Signed and dated this ____________ day of _________________________, 20_________.

_________________________________ Signature of Applicant

____________________________________

Print Name

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Part III - Applicant's Statement I recognized that the aquifer is overappropriated at this location and that in order to allow or consider this change of water right for the well(s) with Permit No(s). ________________________________ without material injury to the rights of other appropriators, the future withdrawals from the well(s) must be limited to prevent an increase over the historic depletions to the aquifer. I am willing to comply with the following conditions to provide for the proper administration of the requested change, if approved. 1. The terms of the Commission's change of water right approval shall be considered as covenants running with the land as described, modifiable in the future only by the Colorado Ground Water Commission or its successors in conformity with Title 37, Article 90 of the Colorado Revised Statutes, also known as the Colorado Ground Water Management Act, as it exists on the date such modification is made. A certified copy of this approval shall be recorded in the public records of the county clerk of the applicable county. Any modifications shall likewise be recorded. Applicant agrees to pay all reasonable costs associated with the administration of the change of water right. The applicant also agrees to enter into a contract with the Commission, local Ground Water Management District ("District"), or a person or entity acceptable to the Commission for this purpose. The change of water right shall not be implemented until the applicant or subsequent well owner have signed a contract with the Commission, District, or a person or entity acceptable to the Commission Contracts with entities other than the Commission or District must be Commission approved. The contracted services required under this administration shall include site inspections covering the peak water use period during the calendar year. Each inspection will include the readings of water-measuring devices and a description of use of water from the subject well(s). Any perceived violation of the permit conditions shall also be reported. A copy of the contractor's inspection report shall be available to the applicant upon request. The Applicant (or the contracted entity) shall be required to report to the Commission and District all readings of the measuring device(s) and total amount(s) pumped by February 15 of each year for the prior calendar year. The Applicant is also required to report the number of kilowatt-hours of electricity, thousand cubic feet of gas, or other fuel used for the prior calendar year. All meter installation information and readings must be reported on forms DBB-003 Administrative Reporting-Meter Information and DBB-004 Administrative Reporting-Meter Readings, respectively, and or any other Commission approved forms. All water volumes must be converted to an acre-foot amount. Incomplete forms shall not be acceptable for fulfillment of reporting requirements. Prior to implementation of the approval of the change of water right, the applicant or subsequent owner shall acquire water-measuring devices satisfactory to the Commission and District, which shall be installed according to the manufacturer's recommendations under the supervision and to the satisfaction of the Commission and the District. These measuring devices shall be inspected annually and promptly repaired or recalibrated as needed whenever it comes to the applicant's attention that they are not in good working condition or whenever so notified by authorized representatives of the Commission or District. All of these obligations shall be fulfilled at applicant's sole expense. No repairs or replacement of parts of said measuring devices shall be made by applicant without prior notification to the Commission and District. All parts replaced shall be retained by applicant and given to Commission or District Representatives who may inspect the measuring devices after their repair or replacement. Any pump shall be turned off by applicant while the measuring device for that well is not working properly or is being repaired or replaced, and shall not be turned on again until approved by the Commission or District. The requirements outlined in Commission Policy Memorandum 95-3, concerning the use of flow meters and power meters, must be met. Applicant is required to observe the water-measuring device(s) and shall be responsible to turn off the

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pump(s) once the withdrawal limit(s) for that year is reached. 9. The applicant hereby authorizes _________________________________ (name of electric or natural gas company or fuel supplier) to release to authorized Commission or District personnel all power use data within its records regarding this well(s).

10. The applicant agrees to allow access to all lands at all reasonable times to representatives of the Commission or District for inspection and other necessary visits to administer this application. The measuring devices must be accessible for examination and reading by the authorized persons. 11. Where applicable, the applicant agrees to make any and all records regarding irrigation from this well(s) at the respective F.S.A. offices available to Commission and District personnel at all reasonable times, and authorizes the release of all such records to Commission and District personnel. 12. Where applicable, the applicant agrees to provide yield records for crops irrigated by this well upon request or accept the appropriate county average yields. 13. Field certification of the water-measuring devices by a certified well tester as determined by the State of Colorado is required every four (4) years as stated in Commission Policy Memorandum 95-3. The well owner shall promptly submit the results of these field certifications to the Commission. Results must be submitted to the Commission on attached form DBB-019(A) Power Consumption Coefficient Rating for Electrical Pumps where electrical pumps are used and on attached form DBB-019(B) Pump and Motor Efficiency Tests must be where non-electrical pumps are used. At least three (3) days prior notice of the date of this test must be given to Commission and District, so that Commission or District personnel might be present during the test.
14. The applicant agrees to pay all court costs and reasonable attorney fees incurred by the Commission and/or

District in any court or administrative action which results in a determination that applicant have violated any provision of this Applicant's Statement or any conditions of the change of water right approval. If in violation of a Commission or State Engineer Order, the violator may be required to pay a sum not to exceed five hundred dollars ($500) for each day such violation continues. Furthermore, if such ground water violation results in the violation of compliance with an interstate compact, the violator shall be liable for all direct, actual, and necessary expenses incurred by the State of Colorado in performing any action, including the purchase of water or payment of damages necessary for the State of Colorado to remedy the violation of such compact. 15. Any person who, when complying with the conditions of this Applicant's Statement, fails to submit data, falsifies or makes a fictitious report of the amount of designated ground water pumped from a well, makes a false or fictitious report of a power coefficient for a well, or falsifies any power coefficient test shall forfeit and pay a sum not to exceed five hundred dollars ($500) for each violation. 16. Also, any person who willfully interferes with or damages a power meter, totalizing flow meter, or other devices used to measure designated ground water diversions or who tampers with or falsifies any record made or being made by any such power meter, totalizing flow meter, or other devices shall forfeit and pay a sum not to exceed five hundred dollars ($500) for each violation. 17. The applicant may be required to agree to additional terms and conditions that are deemed appropriate to prevent material injury to the vested water rights of other appropriators before the approval can be granted or implemented. Signed and dated this ________ day of ____________________________, 20________. ________________________________________________ Signature of Applicant