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

FORM 3.1 - NOTICE OF TOTALIZING FLOW METER

RE-VERIFICATION, INSTALLATION OR REPLACEMENT
To be Filed in Compliance with Rules 3.1 and 4 of the AMENDED RULES GOVERNING THE MEASUREMENT OF TRIBUTARY GROUND WATER DIVERSIONS LOCATED IN THE ARKANSAS RIVER BASIN. SUBMIT TO: DIVISION OF WATER RESOURCES, DIVISION 2 310 E. ABRIENDO, SUITE B PUEBLO, CO 81004 TESTER'S NAME: TELEPHONE: FAX: 719.542.3368 719.544.0800

TEST DATE: STRUCTURE ID NUMBER:

PROVIDE THE FOLLOWING ­ WHETHER OR NOT A STRUCTURE ID HAS BEEN ASSIGNED ­ USING INFORMATION SHOWN ON THE BRASS TAG FOR THE STRUCTURE. IF NO PERMIT OR DECREE IS SHOWN, PLEASE NOTE AS "NA" Well Permit No.: Case or Decree No.:

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

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

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

POWER SUPPLY AND USE: SOURCE OF POWER:
Electric ................. Windmill ............... Fossil Fuel (Gas, Propane, Diesel, etc.) ......... Other: Meter Manufacturer: Manufacturer's Serial No.:
Include all rotating digits Include leading zeros

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: Number of Rotating Digits:

USE (POWER COMPANY METER):
Are other devices, including other Wells/Pumps, served by the same Power Company Meter? Yes ....... No ........ If yes, describe:

FORM31_041108

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04/11/08

FORM 3.1 - NOTICE OF TOTALIZING FLOW METER RE-VERIFICATION, INSTALLATION OR REPLACEMENT

DIVISION 2

INSTALLED TFM INFORMATION:
Manufacturer: Tested Meter or Sensor: Register: Meter Size: Meter Units: Gal.... Multiplier: Meter Horizontal: ..... Orientation: Vertical: ......... Cubic-Feet . Acre-Feet . Other: Number of Recording Digits: Diameters of Upstream: Straight Pipe: Downstream: Test Meter Manufacturer: Calibration Date: Discharge Pipe ID: Diameter: OD: Meter Type: Serial No. Model No.: Multiplier Reading on Test Date
Check which device was read for Test. Provide Register Serial No. ONLY IF Meter has a Remote Readout.

TEST METER INFORMATION:
Test Meter Serial No.:

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: . .
1.051 to 1.080

.
=

(Show Q to nearest 0.00 GPM ) AVG

QI:

.

Correction = Factor

AVG QT AVG QI
0.950 to 1.050

.

Correction Factor must be shown to the nearest 0.000.

No REQUEST FOR VARIANCE is required REQUEST FOR VARIANCE must be submitted with FORM 3.1. REQUEST FOR VARIANCE must be submitted with FORM 3.1.

0.920 to 0.949 OR If Correction Factor is:

0.900 to 0.919 OR

1.081 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.

<0.899
FORM31_041108

OR

>1.101

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04/11/08

FORM 3.1 - NOTICE OF TOTALIZING FLOW METER RE-VERIFICATION, INSTALLATION OR REPLACEMENT

DIVISION 2

USES THROUGH THIS TOTALIZING FLOW METER: Do other Wells, Discharge through this TFM? D ISCHARGE M ETHODS : M ARK A LL T HAT A PPLY
Open Discharge / ... Low Pressure Pipeline: Other: Sprinkler: .....

Yes ....

No...

If yes, list by STRUCTURE ID:

Drip Tape:

....

Pressurized System (including .... Household and Stock Watering):

Describe all discharges AND Provide Detailed Sketch on last page or as Attachment:

METER TESTING
How was the WELL/METER tested with TEST EQUIPMENT (open discharge, pressure, or more than one way)? Show information in detailed sketch on last page or as an attachment.

TESTER VERIFICATION:
I, , state that I am currently approved by the STATE ENGINEER to conduct WATER WELL METER TESTS pursuant to the AMENDED RULES GOVERNING THE MEASUREMENT OF TRIBUTARY GROUND WATER DIVERSIONS IN THE ARKANSAS RIVER BASIN. I have determined the installed TOTALIZING FLOW METER to be in accurate working condition as defined by the Rule 3.1.1 OR have attached a REQUEST FOR A VARIANCE. I understand that "accurate working condition" is determined when the indicated flow through the Installed METER is within plus or minus 5% of an independent field measurement made using CALIBRATED TEST EQUIPMENT.

SIGNATURE:

DATE:

WELL OWNER/USER CERTIFICATION AND CONSENT TO RELEASE OF POWER DATA:
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. If any VARIANCE is requested on my behalf to apply a CORRECTION FACTOR to my TFM, I agree to such VARIANCE. For ELECTRICALLY-POWERED WELLS/PUMPS, I agree to the release of information pertaining to my ELECTRIC SERVICE AND USE, 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. FOR CORRECTION FACTORS THAT ARE ±8.1% ­ 10.0%., I acknowledge that repair and/or replacement of this METER and/or portions of the DISCHARGE SYSTEM is required within one-year of this TEST DATE AND I agree to make the necessary changes within that time.

SIGNATURE:
FORM31_041108

CHECK ONE:

WELL OWNER

WELL USER

DATE:
04/11/08

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FORM 3.1 - NOTICE OF TOTALIZING FLOW METER RE-VERIFICATION, INSTALLATION OR REPLACEMENT

DIVISION 2

DETAILED SKETCH: Show configuration and measurements. Also, show location of TEST EQUIPMENT during TEST. Show TOTAL SYSTEM from PUMP to ALL DISCHARGE POINTS, other PUMPS in the same WELL and electrical system including other devices on the same POWER COMPANY METER. Show where TEST METER and PRESSURE GAUGE (if used) were placed and how SYSTEM was modified to perform TEST. Show measurements. In addition to sketch, an attached photo is recommended.

FORM31_041108

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04/11/08