Form LC-25 Lower Colorado River Well Inventory

LC-25 OMB Approval No.1006-0014

Expiration Date: XX/XX/2015

Lower Colorado River Well Inventory

OMB Approval No. 1006-0014 Expiration Date: XX/XX/2015

Site ID: ___________________________________ Date: ______________ Time (MST): __________ Agency: ____________ Collected by:

Site Name: ________________________________ Land Net: _____ 1/4 _____ 1/4_____ 1/4 Section_______ Township________ Range_______ State:

Other identifier or markings: ______________________________________ GPS file name: ________________________________ County:

Data reliability: C (field checked) L (poor location) M (minimal data) U (unchecked) Agency use: O District code: 04 Station type:

Outer casing ID: _______________ in. Material: Inner casing ID: _______________ in. Material:

Outer casing ht. above land surface (LS): ft Distance between tops of inner and outer casings: ft

Describe reference point for LS:

Condition of well:

Type of power: ________________________ Motor brand: _____________________________ Serial no.: ______________________________ HP:

Power meter no.: _______________________________ Power company:

Type of pump: _________________ Diameter of discharge pipe: ________________ in. Flow rate: ___________cfs / gpm Method of meas:

Photograph no. ____________________, view toward __________, showing

Photograph no. ____________________, view toward __________, showing

________ft _______ from power pole no._____________; _________ft _______ from stop sign; ________ ft ________from street sign; ________ft from canal

________ft _______ from __________________________________________; ________ft _______ from

Additional location information:

Water level (WL) required outside flood plain above Laguna Dam

Tape Held: ft WL measurement method:

WL Cut: ft Measuring point (MP) description:

WL below MP: ft

MP height above LS: ft TD below MP: ft

WL below LS: ft TD below LS: ft

Status of nearby fields, pumps, canals, etc.:

Site status for WL: Source of WL other than measured:

D (dry) G (nearby flowing) J (injector site monitor) P (pumping) T (nearby recently pumped) X (surface-water

E (recently flowing) H (nearby recently flowing) N (measurement discon.) R (recently pumped) V (foreign substance) effects)

F (flowing) I (injector site) O (obstruction) S (nearby pumping) W (well destroyed) Z (other)

Use of site (list all that apply in order of use):

A (anode) E (geothermal) M (mine) R (recharge) U (unused) Z (destroyed)

C (standby emerg.) G (seismic) O (observation) S (repressurize) W (withdrawal)

D (drain) H (heat reservoir) P (oil or gas) T (test) X (waste)

Uses of water (list all that apply in order of use):

A (air cond., comm.) E (power generation) J (industrial cooling) N (industrial other) R (recreational) U (unused)

B (bottling) F (fire fighting) K (mining) P (public supply) S (stock watering) Y (desalination)

C (commercial) H (domestic) M (medicinal) Q (aquaculture) T (institutional) Z (other- explain)

D (dewatering) I (irrigation)

Domestic only: number of single family residences: __________; number of multifamily residences: __________ Swimming pool: yes / no

Stock only: number: __________; type: __________ Irrigation only: number of acres served by this well:__________ ; other source of irrigation water:

Disposal of unconsumed portion of pumped water (list all that apply):

ST (septic tank) SS (sewer system) EP (evaporation pond) SR (surface return PS (percolation into soil) OT (other-explain)

to river)

If sewer system used, include name of municipality operating it:

Property owner’s name (last, first, m.i.):

Property owner’s phone number: ____________________________________________________________________ Date property acquired:

Property owner’s complete mailing address:

Street address of well:

Well operator’s name (last, first, m.i.):

Well operator’s phone number: _____________________________________________________________________ Date operation began:

Please return to: U.S. Geological Survey WRD, 520 North Park Avenue, Tucson, AZ 85719, or call 520-670-6671 Revised 05/18/12

Well operator’s complete mailing address:

Driller’s name (company or individual):

Original well owner: ______________________________________________________________________________ Date well completed:

Annual volume pumped (acre-feet, gallons, cubic meters); (measured, estimated):

Is well within the service area of a water supplier?: ____ Name/address of water supplier:

Well permit no.: Issuing agency:

Federal delivery contract name: Assessor’s parcel no.:

Latitude: UTM Northing: m

Longitude: UTM Easting: m

Lat/Long. Accuracy: UTM Accuracy: _____________________m Zone number: 11

Geographic Datum: Location method:

Elevation of reference point: Elevation of MP: _________________ Elevation method:

Description of reference point for elevation:

A (Altimeter) C (GPS Differential Correction Geographic) L (Level-conventional survey)

B (GPS Autonomous Geographic) D (GPS Differential Correction Geodetic) M (Map)

If Map: Map name: _____________________________ Accuracy: _____________ Scale: _________________ Altitude of LS: ft

LCRAS field numbers watered by well:

Remarks (additional comments or sketches):

Paperwork Reduction Act Notice

The Colorado River Basin Project Act and the Boulder Canyon Project Act authorize collection of this information. The primary use of this information is to determine the contractual status and consumptive use of Colorado River water from wells. Records of volume of water being pumped, consumptive uses, and point of diversion will be disclosed to interested parties upon written request. Public reporting burden for this form is estimated to average 20 minutes per response, including time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Furnishing the information on this form is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number.

Privacy Act Statement

Information contained on this form is protected by the Privacy Act of 1974 and will be maintained in INTERIOR/WBR-48 system of records.