Free Water User Data Submittal Form - Colorado

FORM 6.1

ANNUAL WATER USE REPORTING FORM

PAGE 1

To be Filed in Compliance with Rule 16.8 of the RULES GOVERNING THE MEASUREMENT OF GROUND WATER DIVERSIONS LOCATED IN THE REPUBLICAN RIVER BASIN WITHIN WATER DIVISION NO. 1. To: Division of Water Resources, (Designated Basins Branch) 1313 Sherman St. Rm. #818 Denver, CO 80237 Telephone: FAX: (303)866-3581 (303)866-3589

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

WELL LOCATION AND USE INFORMATION:
Well Permit No.: Structure ID No.:
(if known):

Complete at least one of the following methods of determining location

¼,

¼,

Section

,

Township Ft. from N

,

, S

Range Ft. from

, , E

PM W

Distance of Well from Section Lines

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

This Well Is Principally Used For? .... Irrigation
Please provide a legal description of the acreage irrigated. Include the number of irrigated acres, and the wells involved in the irrigation: ____________________________________________________________________________________ ____________________________________________________________________________________. .... Other (Municipal, Commercial, or Other use)

METER REPORTING INFORMATION FOR CALENDAR YEAR _____________.

Totalizing Flow Meter

Electrical Meter

HAS THIS METER BEEN REMOVED OR REPLACED DURING THE PREVIOUS YEAR? IF SO, EXPLAIN THE CIRCUMSTANCES AND PROVIDE THE REQUESTED INFORMATION IN THE CHART BELOW. _________________.

OLD METER NUMBER

DATE METER REMOVED/REPLACED

READING WHEN REMOVED/REPLACED

NEW METER NUMBER

START READING

END READING

FORM 6.1

ANNUAL WATER USE REPORTING FORM
TOTALIZING FLOW METER REPORTING

PAGE 2

FLOW METER SERIAL NUMBER: VOLUMETRIC UNITS (GALLONS, ACRE-FEET, ETC.): BEGINNING FLOW METER READING: END FLOW METER READING: AMOUNT OF WATER PUMPED FOR ENTIRE PERIOD (IN ACRE-FEET) MULTIPLIER: DATE OF READING: DATE OF READING:

OR
POWER METER REPORTING
POWER COMPANY : POWER CO. ACCOUNT NUMBER: POWER METER SERIAL NUMBER: POWER CONVERSION COEFFICIENT (P.C.C. RATING): BEGINNING POWER METER READING: END POWER METER READING: TOTAL AMOUNT OF WATER PUMPED FOR THE YEAR (IN ACRE-FEET) DATE OF READING: DATE OF READING: DATE OF P.C.C TEST:

OWNER/USER CERTIFICATION AND CONSENT TO RELEASE POWER DATA:
The above information is true and correct to the best of my knowledge. For electrically powered wells/pumps, I agree to the release of information 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 electrical supplier (if applicable) for purposes of verifying water use from the well.

SIGNATURE:

DATE: ________

CHECK ONE:

WELL OWNER WELL USER

FORM 6.1

ANNUAL WATER USE REPORTING FORM

PAGE 3