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FORM 4 - GROUND WATER USER INFORMATION

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To be Filed by the Well Owner/User within 30 Days of a TFM Installation, in Compliance with Rule 4 of the RULES GOVERNING THE MEASUREMENT OF GROUND WATER DIVERSIONS LOCATED IN WATER DIVISION NO. 3, THE RIO GRANDE BASIN. NOTE: A CERTIFIED METER TEST AND FORM 3.1 OR 3.2 MUST BE COMPLETED FOR THIS METER WITHIN 1 YEAR OF INSTALLATION.
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

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)

WELL LOCATION AND INFORMATION:
Well Permit No.: Case or Decree 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

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

METHOD OF WATER MEASUREMENT (MUST CHECK ONE OF THE FOLLOWING ): ... Totalizing Flow Meter ... Electrical meter is owned by a Power Utility AND power data supplied by the Power company
will be used to calculate usage. ... Electrical meter is owned by a Power Utility AND will be monitored and reported by the party responsible for the well and will be used to calculate usage. (a.k.a. "Self-Reporter") NOTE: For wells with an electrical meter owned by a Power Company as the only measurement method, the reporting source (either power company or self) can only be changed at the beginning of the Irrigation Year through a separate request submitted to DWR. ... Another method of water measurement, such as privately owned electric meter, hour meter, etc., (These methods require a variance)

Div 3 Form 4

Updated: 04/01/08

FORM 4 - GROUND WATER USER INFORMATION
ELECTRICAL SUPPLIER: (THE FOLLOWING MUST BE PROVIDED IF WELL IS ELECTRICALLY POWERED):
Power Company: Power Company Account No.: Electric Meter No. or Power Company Service No.: Kilowatt-Hour Meter Reading on Date of Installation. TOTALIZING FLOW METER INFORMATION (IF A FLOW METER IS BEING USED) Totalizing Meter Manufacturer: METER MODEL NUMBER: METER SIZE (IF APPLICABLE): METER SERIAL NUMBER: VOLUMETRIC UNITS (GALLONS, ACREFEET, ETC.): BEGINNING FLOW METER READING: DATE OF INSTALLATION:

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From Power Co. Bill On Power Meter

WATER USE INFORMATION:
NOTE: If a well has more than one pump and the pumps have separate meters, a separate Form 4 must be submitted for each pump. The information shown on each Form 4 must pertain to that specific pump and meter only.

CHECK ONE OF THE FOLLOWING OPTIONS TO INDICATE IF THE FOLLOWING INFORMATION IS FOR: All use of this well. OR ... Only the use of the pump measured by Meter No.: IS THIS WELL/PUMP PRINCIPALLY USED FOR? .... Irrigation (includes agricultural and turf irrigation with untreated water) .... Other (Municipal, Commercial, or Other use) FOR IRRIGATION WELLS ONLY: (Also show information in detailed sketch on last page or as an attachment.) Note: Reporting of reduced acreage, from that quantity legally approved by Water Court Decree and/or a well
permit, does not constitute an abandonment or relinquishment of the reduction in acreage.

Legal Description of Acreage irrigated: Is this land within a groundwater subdistrict? If yes, which one?

Is any of this land in a land or ground water conservation program of the type described in C.R.S. § 37-92-103(2) (a) or (b)? If yes, please describe the program.

Div 3 Form 4

Updated: 04/01/08

FORM 4 - GROUND WATER USER INFORMATION

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Number of acres irrigated by this Well/Pump (or group of wells serving common acreage): Is the acreage served by this well/pump irrigated with groundwater only? If No, what is the source (ditch name) and amount (cfs or shares) of the surface water? Yes .......

Acres No .......

What percentage of the water pumped from this well/pump is used with the following irrigation method? Flood or Furrow: If "other," describe: % Sprinkler: % Drip: % Other: %

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 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:

DATE:

CHECK ONE:

WELL OWNER

WELL USER

Div 3 Form 4

Updated: 04/01/08

FORM 4 - GROUND WATER USER INFORMATION

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DETAILED SKETCH: Show configuration of irrigated land. Draw a detailed map of the land irrigated by this well/pump. Show total system from pump to discharge, other pumps or wells irrigating the same land, locations of any other structures on the land, etc.

Div 3 Form 4

Updated: 04/01/08