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Form 3.1 NOTICE OF TOTALIZING FLOW METER VERIFICATION, RE-VERIFICATION, OR REPLACEMENT
To be Filed in Compliance with Rule 3.1 of the RULES GOVERNING THE MEASUREMENT OF GROUND WATER DIVERSIONS LOCATED IN WATER DIVISION NO. 3, THE RIO GRANDE BASIN.
To: Division Engineer, Water Division No. 3 P. O. Box 269 301 Murphy Drive Alamosa, CO 81101 Telephone: FAX: (719) 589-6683 (719) 589-6685

*TEST DATE: REASON FOR METER VERIFICATION:

*TESTER'S NAME:

........New TFM ­ NO PREVIOUS METER .............. The following MUST be provided for new & replaced meters: ........Previously Verified TFM ..... Date New TFM installed: ........Replacing Previous TFM ............................ Date Previous TFM removed: Previous TFM Serial No.: _______________ ........ Previous TFM Reading: ........Change in Measurement Method from: .. 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(S):
Structure ID No.: Well Permit No: Case or Decree No.:
(if known)

Location

GPS Coordinates of Well(s):

¼¼, Section, Township, Range, PM (format: UTM, Datum: NAD 83)

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:
FIRST WELL: Power Company Name: Power Company Service No.: Power Company Meter Reading on Date of Test: Multiplier: USE (POWER COMPANY METER): Does the same Power Company Meter serve other devices, including other Wells/Pumps? Yes ....... No ......... If yes, describe: Number of Rotating Digits:
Electric Meter Manufacturer:

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

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Form 3.1 NOTICE OF TOTALIZING FLOW METER VERIFICATION, RE-VERIFICATION, OR REPLACEMENT SECOND WELL (IF APPLICABLE):
Power Company Name: Power Company Service No.: Power Company Meter Reading on Date of Test: Multiplier: USE (POWER COMPANY METER): Does the same Power Company Meter serve other devices, including other Wells/Pumps? Yes ....... No ......... If yes, describe: Number of Rotating Digits: Electric Meter Manufacturer: Manufacturer's Serial No.:
Include all rotating digits Include leading zeros

THIRD WELL (IF APPLICABLE):
Power Company Name: Power Company Service No.: Power Company Meter Reading on Date of Test: Multiplier: USE (POWER COMPANY METER): Does the same Power Company Meter serve other devices, including other Wells/Pumps? Yes ....... No ......... If yes, describe: Number of Rotating Digits: Electric Meter Manufacturer: Manufacturer's Serial No.:
Include all rotating digits Include leading zeros

INSTALLED TFM INFORMATION:
Manufacturer: Serial No.(s) Sensor:
(Indicate Meter/Register)

Model No.: Meter Reading on Test Date: Meter Type: Cubic-Feet.. Acre-Feet.. Other: Number of Recording Digits: Diameters of Upstream: Straight Pipe: Downstream: Discharge Pipe ID: Diameter: OD: Register:

Meter Size: Meter Units: Gal.... Multiplier: Meter Horizontal: ..... Orientation: Vertical: .........

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

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Form 3.1 NOTICE OF TOTALIZING FLOW METER VERIFICATION, RE-VERIFICATION, OR REPLACEMENT
TEST METER INFORMATION:
Test Meter Manufacturer: Test Meter Serial No.: Horizontal: ..... Test Meter Orientation: Vertical: ......... Test Meter Type: GPM Factor (Collins Meter): Date of last Calibration Diameters of Upstream: Straight Pipe Downstream: from Test Site: ID: Pipe Diameter at Test Site: OD:

Pipe Wall Thickness at Test Site: (Inches):

VERIFICATION OF INSTALLED METER:
SEAL NUMBER (Required on all programmable flow meters ­ i.e. magnetic meters): New
Removed: *All programmable flow meters must have a tamper resistant cover and seal (numbered) as outlined in Policy 2008-3.1.C. **COLLINS METER (only) ­ Include stop settings in table below.

TEST METER CALCULATIONS (SHOW ALL WORK)

INSTALLED METER CALCULATIONS (SHOW ALL WORK):

(Show Q to nearest 0.0 GPM )

AVG QT: =

(Show Q to nearest 0.0 GPM )

AVG QI:

Correction = Factor

AVG QT AVG QI
0.950 to 1.050

Correction Factor must be shown to the nearest 0.000.

The installed TFM is in accurate working condition.
This TEST will be rejected and the installed TFM must be repaired or replaced AND a new TEST conducted. *If TFM fails test and is re-calibrated (k-factor modified) ­ show failed test, indicate below k-factor before and after, AND show new test on additional duplicate page (include failed and passed test page 3). k-factor (after)_______ . Failed Test: k-factor (before) Division of Water Resources, Division 3 may grant a request for a variance to allow the use of a CORRECTION FACTOR computed by a Qualified Well Tester for totalizing flow meters that measure within plus or minus 5% up to 8% of an independent field measurement made using calibrated test equipment. If a variance is being requested, the bottom of the following page (page 4) must be completed, including the well owner/users agreement of all conditions regarding a granted variance request to allow a Correction Factor.

If Correction Factor is:

< 0.950

OR

> 1.050

If Correction <0.920 >0.950 OR (between) Factor is:

<1.050 >1.080

(between)

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Form 3.1 NOTICE OF TOTALIZING FLOW METER VERIFICATION, RE-VERIFICATION, OR REPLACEMENT
DISCHARGE METHODS: MARK ALL THAT APPLY
Open Discharge / ... Low Pressure Pipeline: Other: Sprinkler: ..... Drip Tape: ..... Pressurized System (including ..... humidification use):

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.

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 RIO GRANDE BASIN. I have determined the installed TOTALIZING FLOW METER to be in accurate working condition as defined by the Rule 3.1.1. Accurate working condition is determined when the indicated flow of the meter is within plus or minus 5% 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.

SIGNATURE:
CHECK
ONE:

DATE:
WELL OWNER WELL USER

VARIANCE REQUEST TO USE CORRECTION FACTOR FOR TFM BETWEEN 5-8% (VARIANCE REQUEST ONLY):
I request a variance to allow the use of the Correction Factor noted on page 3 as computed by the above Qualified Well Tester. I understand and agree to the following REQUIRED CONDITIONS of the variance AND all items outlined in Policy 2007-3.1-B: · · · · · The variance will utilize the CORRECTION FACTOR computed by a Qualified Well Tester for a maximum of 1-year. A new CORRECTION FACTOR computed by a Qualified Well Tester shall be required each year thereafter. A variance will only be allowed for an individual totalizing flow meter for a maximum of 3-years. After 3-years the totalizing flow meter must be repaired or replaced and working within the required plus or minus 5%. Current CORRECTION FACTOR WILL be applied to ALL use records for that following one 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 8% 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: CHECK
ONE:

SIGNATURE:
WELL OWNER WELL USER

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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 photo is recommended.

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