Water Right Self-Assessment Form for Small Water System Management Programs and Project Reports System Name: System ID#: Type of System: Proposed Type of System: (Group A Comm, NTNC, TNC, Group B, or New) (if changing) Water Right FOR Existing Water Rights Permit, Certificate, WFI Source # Qi = Instantaneous Flow Rate Allowed (GPM or CFS) Qa = Annual Volume Allowed (Acre Feet/Year) Claim # or Exempt SUPPLIERS ONLY: If a source has multiple *If water right is Name on Water Right Does water right water rights, list each Primary Qa Non-Additive Primary Qi interruptible, identify identify a number of water right on separate Qi Annual Qa Maximum Rate limitation in yellow connections? If yes, line Maximum Volume Annual Volume Allowed section below how many? Rate Allowed Allowed Allowed 1 2 3 4 TOTALS = A B Column Identifiers for Calculations: Current Source Production – Most Recent Calendar Year Forecasted Source Production at Full System Build Out Interruptible Water Rights Qi=Maximum Instantaneous Withdrawal from Source. (GPM or Projected maximum withdrawal from source at full build out. Identify limitations on any water rights listed CFS) This includes wholesale water provided to other systems above that are interruptible Qa=Maximum Annual Volume Withdrawn (Acre Feet/Year) This includes wholesale water provided to other systems Total Qi Excess or Total Qa Excess or Excess or Excess or Permit or Time Period of Instantaneous (Deficiency) Annual (Deficiency) Instantaneous (Deficiency) Annual (Deficiency) certificate # Interruption Flow Rate Qi Volume Qa Flow Rate Qi Volume Qa C =A-C D =B-D E =A-E F =B-F INTERTIES: Systems receiving wholesale water complete this section. Wholesaling systems must include water sold through interties in the source production columns above. Name of Wholesaling Quantities Allowed Currently Purchased Forecasted Purchase at Full System Build Out System Providing Water In Contract Quantity currently purchased through intertie Forecasted quantity purchased through intertie Excess or Excess or Excess or Maximum Maximum Instantaneous (Deficiency) Annual Instantaneous Annual (Deficiency) Qi Qa Flow Rate Qi Volume Flow Rate Volume Qa Qi
Water Right Self-Assessment Form for Small Water System Management Programs and Project Reports System Name: System ID#: Type of System: (Group A Comm, NTNC, TNC, Group B, or New) Proposed Type of System: (if changing) Water Right Permit, Certificate, Claim # or Exempt *If water right is interruptible, identify limitation in yellow section below Name on Water Right FOR SUPPLIERS ONLY: Does water right identify a number of connections? If yes, how many? WFI Source # If a source has multiple water rights, list each water right on separate line Existing Water Rights Qi = Instantaneous Flow Rate Allowed (GPM or CFS) Qa = Annual Volume Allowed (Acre Feet/Year) Primary Qi Maximum Rate Allowed Qi Maximum Rate Allowed Primary Qa Annual Volume Allowed Non-Additive Qa Annual Volume Allowed 1 2 3 4 TOTALS = Column Identifiers for Calculations: A B Current Source Production – Most Recent Calendar Year Qi=Maximum Instantaneous Withdrawal from Source. (GPM or CFS) Qa=Maximum Annual Volume Withdrawn (Acre Feet/Year) This includes wholesale water provided to other systems Forecasted Source Production at Full System Build Out Projected maximum withdrawal from source at full build out. This includes wholesale water provided to other systems Interruptible Water Rights Identify limitations on any water rights listed above that are interruptible Total Qi Instantaneous Flow Rate Excess or (Deficiency) Qi Total Qa Annual Volume Excess or (Deficiency) Qa Instantaneous Flow Rate Excess or (Deficiency) Qi Annual Volume Excess or (Deficiency) Qa Permit or certificate # Time Period of Interruption C =A-C D =B-D E =A-E F =B-F INTERTIES: Systems receiving wholesale water complete this section. Wholesaling systems must include water sold through interties in the source production columns above. Name of Wholesaling System Providing Water Quantities Allowed In Contract Currently Purchased Quantity currently purchased through intertie Forecasted Purchase at Full System Build Out Forecasted quantity purchased through intertie Maximum Qi Maximum Qa Instantaneous Flow Rate Excess or (Deficiency) Qi Annual Volume Instantaneous Flow Rate Excess or Qi Annual Volume Excess or (Deficiency) Qa
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