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FORM 6.1

WATER USE DATA SUBMITTAL FORM (TOTALIZING FLOW METER)

To be Filed in Compliance with Rule 6 of the RULES GOVERNING THE MEASUREMENT OF GROUND WATER DIVERSIONS LOCATED IN WATER DIVISION 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

CONTACT INFORMATION (*EMAIL IS REQUIRED FOR ON-LINE METER READING REPORTING):
OWNER Name: Address: City, State, Zip: Phone: *E-Mail: USER (IF NOT SAME AS OWNER)

TOTALIZING FLOW METER REPORTING INFORMATION: (REQUIRED) (REQUIRED) (REQUIRED)

Flow Meter Serial Number
(Sensor & Register If Applicable)

Date Of Meter Reading
(mm/dd/yyyy)

Actual Water Meter Reading (Record ALL DIGITS)

*Additional Flow Meter Readings may be recorded on the back of this form. Examples of reporting are included on the back of this form.

HAS THIS METER BEEN REMOVED OR REPLACED DURING THE PREVIOUS YEAR? IF SO, EXPLAIN THE CIRCUMSTANCE AND THE METER READING BEFORE AND AFTER REMOVAL. 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

Updated 04/01/2008

FORM 6.1

WATER USE DATA SUBMITTAL FORM (TOTALIZING FLOW METER)

TOTALIZING FLOW METER REPORTING INFORMATION (CONTINUED): (REQUIRED)

(REQUIRED)

(REQUIRED)

Flow Meter Serial Number
(Sensor & Register If Applicable)

Date Of Meter Reading
(mm/dd/yyyy)

Actual Water Meter Reading (Record ALL DIGITS)

Example Flow Meter Serial Numbers:

1) McCrometer (typical but not all inclusive): 06-12-5421 (year manufactured-size of flow meter-number) 2) SLV Hydromag: 01061411 / 01061434: the flow meter register (read-out) and sensor will have separate serial numbers. Record
both serial numbers, indicating if it is the Register or Sensor. Example: 01061411R / 01061434S (Register=R, Sensor=S).

Updated 04/01/2008