Free Form 3.1 - Notice of Totalizing Flow Meter, Re-Verification, Installation or Replacement - Colorado

Form 3.1 NOTICE OF TOTALIZING FLOW METER VERIFICATION, RE-VERIFICATION, OR REPLACEMENT
To be Filed in Compliance with Rule 16.5 of the RULES GOVERNING THE MEASUREMENT OF GROUND WATER DIVERSIONS LOCATED IN THE REPUBLICAN RIVER BASIN WITHIN WATER DIVISION NO. 1.
To: Division Engineer, Water Division No. 1 1313 Sherman Street, Suite 818 Denver, CO 80203 Telephone: FAX: (303) 866-3581 (303) 866-3589

*TEST DATE: __________*TESTER'S NAME AND PHONE NO.:

______________________________________

REASON FOR METER VERIFICATION:
New TFM ­ NO PREVIOUS METER Previously Verified TFM Replacing Previous TFM Previous TFM Serial No.: Change in Measurement Method from: Former Measurement Method:

The following MUST be provided for new & replaced meters:
Date New TFM installed: Date Previous TFM removed: Previous TFM Reading: Hour Meter Slave Meter

Power Co. Meter

CONTACT INFORMATION:
OWNER Name: Address: City, State, Zip: Phone: E-Mail: USER (IF NOT SAME AS OWNER)

LOCATION AND INFORMATION OF WELL:
Well Permit No: ¼, ¼, Section Structure ID No.:
(if known)

,

Township
DATUM: NAD 83)

,

Range

,

PM

GPS COORDINATES OF WELL (OPTIONAL): (FORMAT: UTM, Power Supply and Use: SOURCE OF POWER TO WELL(S):
Electric Windmill

Fossil Fuel (Gas, Propane, Diesel, etc.) Other:

Artesian

Solar

PROVIDE THE FOLLOWING FOR ALL WELLS WITH ELECTRIC POWER:

Power Company Name: Power Company Service No.: Power Company Meter Reading on Date of Test: Multiplier:

Electric Meter Manufacturer:

Manufacturer's Serial No.:
Include all rotating digits Include leading zeros ______________________

Number of Rotating Digits:

Div 1. Republican River Form 3.1

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Updated 09/10/08

Form 3.1 NOTICE OF TOTALIZING FLOW METER VERIFICATION, RE-VERIFICATION, OR REPLACEMENT
USE (POWER COMPANY METER): Does the same Power Company Meter serve other devices, including other Wells/Pumps? Yes No If yes, describe:

INSTALLED TFM INFORMATION:
Manufacturer:
Serial No. Multiplier

Model No.:
Reading on Test Date

Sensor: Meter:
Provide Sensor Serial No. ONLY IF Meter has a Remote Readout. Provide both Sensor and Meter Readings ONLY IF Readings differ

Meter Size: Meter Units: Gal. Multiplier: Meter Horizontal: Orientation: Vertical: Yes No Cubic-Feet Acre-Feet Other:

Meter Type: Number of Recording Digits: Diameters of Upstream: Straight Pipe: Downstream: Discharge Pipe ID:___________ Diameter: OD:__________

Is the meter installed to the manufacturer's specifications?

TEST METER INFORMATION:
Test Meter Manufacturer: Test Meter Orientation: Horizontal: Vertical: Diameters of Straight Pipe Upstream:_______ from Test Site: Downstream:____ Calibration Date: ________ Pipe Diameter at Test Site: ID:_______ OD:_______

Test Meter Serial No.:

Pipe Wall Thickness at (Inches): Test Site:

VERIFICATION OF INSTALLED METER (IF MORE THAN ONE METER TESTED FOR SAME DISCHARGE, SHOW ALL TESTS):
TEST METER CALCULATIONS (SHOW ALL WORK) INSTALLED METER CALCULATIONS (SHOW ALL WORK):

(Show Q to nearest 0.00 GPM ) AVG

QT: . .

.
=

(Show Q to nearest 0.00 GPM ) AVG

QI:

.

Correction = Factor

AVG QT AVG QI

.

Correction Factor must be shown to the nearest 0.000.
Updated 09/10/08

Div 1. Republican River Form 3.1

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Form 3.1 NOTICE OF TOTALIZING FLOW METER VERIFICATION, RE-VERIFICATION, OR REPLACEMENT
0.950 to 1.050 0.920 to 0.950 If Correction Factor is: OR 1.050 to 1.080 No REQUEST FOR VARIANCE is required REQUEST FOR VARIANCE must be submitted. REQUEST FOR VARIANCE must be submitted. 0.900 to 0.920 OR 1.080 to 1.10 TEST WILL BE VALID FOR ONE YEAR ONLY. No later than one year from the date of this Test a new MEASUREMENT TEST must be conducted and the ACCURACY of the new TEST must be within ±8.0%. UNACCEPTABLE; METER/SYSTEM must be repaired/replaced.

<0.900

OR

>1.100

IF APPLICABLE PROVIDE A BACK-UP POWER CONSUMPTION COEFFICIENT RATING (PCC): COMPLEX AND COMPOUND
SYSTEM INCLUDED

Kh factor:

Meter Multiplier: Pkh = Kh x Multiplier =

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

Average Rate: Power demand, P = Average Rate x 3.6 x Pkh =

KW

to nearest 0.0000

CALCULATION OF POWER CONSUMPTION COEFFICIENT:

PCC =

5433 x P

QT

=

KWH/AF

PCC must be shown to the nearest 0.0

DISCHARGE METHODS: MARK ALL THAT APPLY
Open Discharge /Low Pressure Pipeline: Sprinkler: Drip Tape: Pressurized System (including humidification use):

Other: ________ Sprinkler Operating Normal Speed

% Speed Running:____ If Sprinkler Off Why? _______

METER TESTING:
Describe all discharges AND Provide Detailed Sketch on last page or as Attachment. Also, how was the
well/meter tested with test equipment (open discharge, pressure or pipe, or more than one way)? Also show information in detailed sketch on last page or as an attachment.

Div 1. Republican River Form 3.1

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Form 3.1 NOTICE OF TOTALIZING FLOW METER VERIFICATION, RE-VERIFICATION, OR REPLACEMENT
TESTER VERIFICATION (MUST BE COMPLETED FOR ALL TESTS): I, , state that I am currently a person approved by the State Engineer to conduct well tests pursuant to the RULES GOVERNING THE MEASUREMENT OF GROUND WATER DIVERSIONS IN THE REPUBLICAN RIVER BASIN. I have determined the installed TOTALIZING FLOW METER to be in accurate working condition as defined by the Rule 16.1. Accurate working condition is determined when the indicated flow of the meter is within plus or minus 5% (unless a variance is requested as stated below) of an independent field measurement made using CALIBRATED TEST EQUIPMENT. Based on the information contained on this form, I represent this test as being an accurate method of determining water use from the WELL/PUMP and as being in compliance with the RULES. I understand that falsifying this test can subject me to a fine of up to $500.00. SIGNATURE: DATE:

WELL OWNER/USER CERTIFICATION AND CONSENT TO RELEASE OF POWER DATA (MUST BE COMPLETED FOR ALL TESTS):
The above information is true to the best of my knowledge. I understand that falsifying the accuracy and/or condition of a TOTALIZING FLOW METER can subject me to a fine of up to $500.00. For ELECTRICALLY-POWERED WELLS/PUMPS, I agree to the release of information pertaining to my use of electrical energy to pump ground water including CURRENT TRANSFORMER FACTOR, VOLTAGE/POTENTIAL TRANSFORMER FACTOR, and ELECTRIC METER READINGS, to the COLORADO DIVISION OF WATER RESOURCES by my electric supplier for the purposes of determining or verifying WATER USE from the WELL/PUMP.

I attest that this well is irrigating ________acres with this well.

SIGNATURE:
CHECK
ONE:

DATE:
WELL OWNER WELL USER

VARIANCE REQUEST TO USE CORRECTION FACTOR FOR TFM BETWEEN 5-10% (VARIANCE REQUEST ONLY):
I request a variance to allow the use of the Correction Factor as computed by the above Qualified Well Tester. I understand and agree to the following REQUIRED CONDITIONS of the variance: · · · · The variance will utilize the CORRECTION FACTOR computed by a Qualified Well Tester for a maximum of four-years if the correction factor is between 5-8%. If Correction Factor is between 8-10% TEST WILL BE VALID FOR ONE YEAR ONLY. No later than one year from the date of this Test a new MEASUREMENT TEST must be conducted and the ACCURACY of the new TEST must be within ±8.0%. Current CORRECTION FACTOR WILL be applied to ALL use records for that flow meter following the four year period, unless the TFM is repaired or replaced. A variance WILL NOT be issued to allow a CORRECTION FACTOR for totalizing flow meters above the required 5% accuracy up to 10% if the inaccuracy is due to the totalizing flow meter or appurtenance being intentionally damaged or modified by the owner and/or user of the well. DATE: WELL OWNER WELL USER

SIGNATURE:
CHECK
ONE:

Div 1. Republican River Form 3.1

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Form 3.1 NOTICE OF TOTALIZING FLOW METER VERIFICATION, RE-VERIFICATION, OR REPLACEMENT
DETAILED SKETCH: 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 (if used) were placed and how system was modified to perform test. Show ALL pertinent measurements (distances) as required to locate all items indicated on drawing such as well, test meter, installed flow meter, bends in pipe, valves, etc. In addition to sketch, an attached digital photo is recommended.

Div 1. Republican River Form 3.1

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Updated 09/10/08