Drinking Water and Groundwater Bureau

NHDES-W-03-170

Water Use

Registration Form

Drinking Water and Groundwater Bureau

Water Use Registration and Reporting Program

RSA 488:3/Env-Wq 2102

Introduction:

Pursuant to RSA 488:3 and Env-Wq 2102, any water user in the state who withdraws or discharges an average of 20,000 gallons of water per day (gpd) in any 7-day period or exceeds a total volume of 600,000 gallons over any 30-day period is required to become a registered water user and report water use data to the NHDES Water Use Registration and Reporting Program (WURR). Some water users not meeting the above thresholds are also required to become registered water users, including but not limited to water users in the state subject to Env-Wq 2101, Water Conservation rules, and water users receiving approved permits from NHDES conditioned upon reporting to WURR.

Instructions:

To register a facility as a water user with WURR, please complete the following form. This form is generic in nature. Please provide the requested information to the best of your ability, and if a particular entry does not apply to your facility, indicate N/A (not applicable) in the space provided.

Attachments:

For non-agricultural uses, a topographic map or aerial photo must be submitted along with the registration form. The map should depict the location of the facility as well as sources and destinations. Enough detail should be included for NHDES staff to locate the sources and destinations (ex. property boundaries, labels of nearby roads).

For agricultural use, a recent aerial photo from the USDA Farm Service, the National Agricultural Imagery Program, or other source that provides equal or higher quality and resolution, must be submitted along with the registration form. The aerial should include a north-pointing arrow, the approximate scale of the image, the date of flight, all withdrawal and discharge points, and boundaries of contiguous areas of 5 acres or more subject to irrigation.

Please return this form to:

NHDES Drinking Water & Groundwater Bureau

Attn: Stacey Herbold

PO Box 95, Concord, NH 03302-0095

FAX: (603) 271-0656 Phone: (603) 271-6685

Upon receiving a completed form, NHDES will assign a Water Use ID# to the water user and provide further instructions on reporting water use data.

Water Use

Registration Form

Drinking Water and Groundwater Bureau

Water Use Registration and Reporting Program

RSA 488:3/Env-Wq 2102

OWNER INFORMATION

Name of Water User (on file with Secretary of State) ______

Owner of Record ______Phone ______Name

Address ______

PO Box – Street #

______

City or Town State Zip Code

FACILITY INFORMATION

Name of Facility ______

Location of Facility ______

Street # Street Name

______

City or Town State Zip Code

FACILITY CONTACT PERSON

Contact Person ______

Name Title

Address ______

PO Box – Street #

______

City or Town State Zip Code

Phone______Email______

TYPE OF WATER USE

Please describe the primary type of water use and check all water uses that apply in the table below: ______

General Use / Agricultural / Power Production
Public Water Supply / Dust Control / Field Crop Irrigation / Biomass
Bottled / Bulk Water / General Irrigation / Greenhouse Irrigation / Fossil Fuel
Wastewater Treatment / Golf Course Irrigation / Nursery Stock Irrigation / Geothermal
Commercial / Athletic Field Irrigation / Livestock / Hydroelectric
Industrial / Domestic/Sanitary / Log Spraying / Lumber / Nuclear
Institutional / Cooling/Heating / Aquaculture
Snowmaking / Cleaning Produce
Mining / Cleaning Equipment

North American Industry Classification Code: ______

Standard Industrial Classification Code: ______ove: ve: utional) Irrigation (Athletic Field ome.ekend - in h 1.up by February 10th.XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

WATER USE DETAILS

Irrigation

Number of acres irrigated during a season: ______

Irrigation system make/model(s): ______

For agricultural users, please attach a description of irrigation methods used, including irrigation types (ex. travelling gun, linear move), watering needs in inches based on crop type and acres of each crop, and watering schedule.

For golf courses, please attach the number of sprinkler heads; the make, model, and gallons per minute of each head; the acres irrigated per head type and which parts of the course the heads are used on (ex. greens); and a typical weekly irrigation schedule.

Domestic Use

Number of people served per day: ______

Number of water-using fixtures/appliances:

Fixtures/Appliances / # of / Fixtures/Appliances / # of
Toilets / Bathroom sinks
Urinals / Kitchen sinks
Showers / Washing machines
Bathtubs (w/out shower) / Dishwashers
Utility sinks / Other:

Heating and Cooling

For heating/cooling, check how water is used: makeup water blowdown contact non-contact

Other: ______

Reuse of Water

Percentage of water recycled: ______% Description: ______

______

Percentage of wastewater reclaimed: ______% Description: ______

______

Hydroelectric

Average operating head (feet above intake)
Average operating efficiency (in percent)
Minimum necessary operating flow (cfs)
Maximum existing capacity (kilowatts)
Maximum turbine design flow (cfs)
Minimum flow release necessary to comply with operating permits (cfs)

ESTIMATED WATER USE

Cumulative from all sources

AVG Daily ______gal MAX Daily ______gal Annual Use ______gal

PERMITS HELD

Please check and provide permit numbers for all that apply.

Permit Type / Permit Number
NPDES Permit
FERC Permit
Public Water Supply Permit
Groundwater Discharge Permit
Large Ground Water Withdrawal Permit
Industrial Pre-Treatment Permit
Any 401 Water Quality certificate stipulating withdrawal amounts
Other Permit Type:

SOURCE INFORMATION

A source may be a groundwater or surface water supply from which water is withdrawn or another facility from which water is transferred. Please provide the below information for each source and label each source on the map described on page 1.

Source Name: ______

Groundwater Surface Water Water Supplier: ______

Name of Supplier

If groundwater, type of well:

Drilled in gravel Drilled in bedrock Dug Other (describe): ______

Source Location: ______

Street Town Zip

Is this source used for all the water uses checked under “Type of Water Use” on page 3? YES NO

If no, which specific uses is this source used for? ______

______

How is the amount of water withdrawn or transferred from the source measured?

Meter Flume/Weir Other: ______

Is there a permit limit on the withdrawal or transfer from the source? Yes No

If yes, what is the limit? ______Units: ______

What is the physical limit the facility can withdraw or transfer from the source based on current facility infrastructure? (ex. pump capacity): ______Units: ______

Please describe the factors affecting the facility physical limit of the withdrawal or transfer from the source:

______

Please make additional copies of this page if there is more than one source.

DESTINATION INFORMATION

A destination means a location to where water is discharged, a facility to where water is transferred, a product into which water is incorporated, and evaporative losses resulting from water usage. Please provide the following information for each destination and label each destination on the map described on page 1.

Destination Name: ______

Destination Location: ______

Street Town Zip

Method of measurement of flow to destination:

Meter Flume/Weir Other: ______

Please check the best description of the destination:

Groundwater / Evaporative losses (ex. from heating/cooling)
Surface water / Water-containing product
Wastewater treatment facility / Snowmaking
Leach field / Irrigation
Delivered to others (specify facility): / Other (describe):

Is there a permit limit on the amount of water which can be discharged or transferred to this destination? Yes No

If yes, what is the limit? ______Units: ______

What is the physical limit the facility can discharge or transfer to this destination based on facility infrastructure? (ex. pump capacity): ______Units: ______

Please describe the factors affecting the facility physical limit of discharge or transfer to the destination:

______

Please make additional copies of this page if there is more than one destination.

2015-11-18 (603) 271-2513 Page 1 of 6

PO Box 95, Concord, NH 03302-0095