NHDES-W-03-105
Water Use
Add Source or Destination 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, registered water users with the NHDES Water Use Registration and Reporting Program (WURR) must register each source of water and each destination of water and report monthly volumes of withdrawal and discharge to WURR. A source may be a groundwater or surface water supply from which water is withdrawn or another facility from which water is transferred. A destination may be 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.
Instructions:
If an existing registered water user adds a new source or destination, this form shall be submitted to NHDES to add the new source or destination to the registration. 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.
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
FACILITY INFORMATION
Name of Facility: ______
Facility Town: ______Water User ID #: ______
Contact Person: ______
Name Title
Phone:______Email: ______
Water Use
Add a Source or Destination Form
Drinking Water and Groundwater Bureau
Water Use Registration and Reporting Program
ADDITIONAL SOURCEINFORMATION
A source may be a groundwater or surface water supply from which water is withdrawn or another facility from which water is transferred.
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 TownZip Code
Is this source for a specific type of water use (ex. fire suppression, dust suppression, irrigation)?______
How is the amount of water withdrawn or transferred from the source measured?
Meter Flume/Weir Other:______
State or federal permit names and numbers related to this source: ______
______
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 transferfrom the source based on current facility infrastructure?(ex. pump capacity): ______Units:______
Please describe the factors affecting the facility physical limitof the withdrawal or transfer from the source:
______
Please make additional copies of this page if there is more than one source to be added.
ADDITIONAL 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.
Destination Name: ______
Destination Location: ______
Street TownZip Code
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:______
State or federal permit names and numbers related to this discharge: ______
______
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 to be added.
(603) 271-2513
PO Box 95, Concord, NH 03302-0095
2015-12-17 1 of 5