Free Form 11A - Variance Request for Alternative Method of Measurement Using Power Meters and Associated Power Conversion Coefficient - Colorado

FORM 11A ­ VARIANCE REQUEST FOR AN ALTERNATIVE METHOD OF MEASUREMENT (POWER CONVERSION COEFFICIENT)
To: Division of Water Resources, Division 1 (Republican River Basin) 1313 Sherman St. Rm. #818 Denver, CO 80203 Telephone: FAX: (303)866-3581 (303)866-3589

CONTACT INFORMATION:
OWNER (IF CHANGED, PROVIDE "CHANGE IN OWNERSHIP/ADDRESS" FORM) Name: Address: City, State, Zip: Phone: E-Mail: USER (IF NOT SAME AS OWNER)

Please be advised, the Power Conversion Coefficient (PCC) as an alternative method of measurement may not be utilized if the well(s) are part of a Complex or Compound System, or if the pump is not powered by electricity, or the Well produces from a confined aquifer. `Compound System' means a system where the power meter records electrical usage from an electrical device other than the pumping systems from a single well and its attached sprinklers. `Complex System' means any system where the total dynamic head at the pump will vary due to multiple discharge locations in a pipeline, or where the method of delivery will vary between open discharge, gated pipe, or sprinkler system during a single irrigation season, or where multiple Wells discharge into a common pipeline.

LOCATION AND INFORMATION OF WELL(S):
Must describe the location of the well(s) using either distances from section lines or GPS coordinates DWR Structure ID No.: Well Permit No.:
(if known)

Location; Distances from section lines, ¼¼, Section, Township, Range, PM

GPS COORDINATES OF WELL(S):
(FORMAT: UTM, DATUM: NAD 83)

SOURCE OF POWER TO WELL(S):
Electric................. Windmill............... Fossil Fuel (Gas, Propane, Diesel, etc.) ......... Other: Artesian............ Solar.................

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FORM 11A ­ VARIANCE REQUEST FOR AN ALTERNATIVE METHOD OF MEASUREMENT (POWER CONVERSION COEFFICIENT)
WATER USE INFORMATION: IS THIS WELL(S)/PUMP(S) PRINCIPALLY USED FOR? .... Irrigation (includes agricultural and turf irrigation with untreated water) .... Other (Municipal, Commercial, or Other use)

FOR IRRIGATION WELLS ONLY:
Number of acres irrigated by this Well(s)/Pump(s) (or group of wells serving common acreage): Note: Reporting of less acreage than the quantity legally approved by
Water Court Decree and/or a well permit, does not constitute an abandonment or relinquishment of the unclaimed acreage.

Acres
If the land area is irrigated by more than one well, please list the additional well permits involved:

PLEASE SUPPLY THE PCC WELL TEST (FORM 3.2) ALONG WITH THIS VARIANCE REQUEST. PLEASE CLEARLY DESCRIBE HOW THE IRRIGATION SYSTEM WAS OPERATING WHEN THE WELL TEST WAS PERFORMED (WHAT WELLS AND SPRINKLERS WERE OPERATING? WHAT LAND WAS IRRIGATED? WILL THIS BE THE NORMAL OPERATING CONDITIONS?). PLEASE DESCRIBE WHAT WELLS AND ELECTRICAL EQUIPMENT ARE CONNECTED TO THE POWER METER.

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FORM 11A ­ VARIANCE REQUEST FOR AN ALTERNATIVE METHOD OF MEASUREMENT (POWER CONVERSION COEFFICIENT)
WELL OWNER OR USER CERTIFICATION: The above information is true to the best of my knowledge. I agree to the release of information
pertaining to my use of electrical energy use 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(S) AND/OR PUMP(S) THAT ARE THE SUBJECT OF THIS VARIANCE REQUEST.

SIGNATURE OF WELL OWNER/USER:

DATE:

DETAILED SKETCH: FOR IRRIGATION USE, draw a detailed map of the land irrigated by the wells/pumps. FOR ALL REQUESTS, show total system from pump to discharge, other pumps or wells irrigating the same land, locations of any other structures on the land, etc.

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