"Water Withdrawal Reporting Form" - New York

Water Withdrawal Reporting Form is a legal document that was released by the New York State Department of Environmental Conservation - a government authority operating within New York.

Form Details:

  • Released on March 1, 2020;
  • The latest edition currently provided by the New York State Department of Environmental Conservation;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the New York State Department of Environmental Conservation.

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March 2020
New York State Department of Environmental Conservation
Division of Water, Bureau of Water Resources Management
625 Broadway, Albany, NY 12233-3508
Water Withdrawal Reporting Form
st
Due by
March 31
of each year
Prior to filling out this form, please read the instructions on the last page
Section 1 of 6 – Basic Information
Facility Name
Facility Street Address
Reporting Year
City
Zip
Town
County
Water Withdrawal Category
(Check One)
Contact Name
Email
Telephone
Agricultural
Bottled / Bulk Water
Source Name
Source Type
Well Depth
Max Rate
Units
Commercial
Environmental
Source Name
Source Type
Well Depth
Max Rate
Units
Industrial
Source Name
Source Type
Well Depth
Max Rate
Units
Institutional
Mine Dewatering
Source Name
Source Type
Well Depth
Max Rate
Units
Oil / Gas Production
Power Production:
Source Name
Source Type
Well Depth
Max Rate
Units
Fossil Fuel
Source Name
Source Type
Well Depth
Max Rate
Units
Nuclear
Other Pwr
Source Name
Source Type
Well Depth
Max Rate
Units
Public Water Supply
Recreational:
Golf Course
Snow Making
Average Day Withdrawal
Units
Maximum Day Withdrawal
Units
NYSDEC Permitted Withdrawal
Units
Other Rec
Other Category
Submitted By:
Title
Date
March 2020
New York State Department of Environmental Conservation
Division of Water, Bureau of Water Resources Management
625 Broadway, Albany, NY 12233-3508
Water Withdrawal Reporting Form
st
Due by
March 31
of each year
Prior to filling out this form, please read the instructions on the last page
Section 1 of 6 – Basic Information
Facility Name
Facility Street Address
Reporting Year
City
Zip
Town
County
Water Withdrawal Category
(Check One)
Contact Name
Email
Telephone
Agricultural
Bottled / Bulk Water
Source Name
Source Type
Well Depth
Max Rate
Units
Commercial
Environmental
Source Name
Source Type
Well Depth
Max Rate
Units
Industrial
Source Name
Source Type
Well Depth
Max Rate
Units
Institutional
Mine Dewatering
Source Name
Source Type
Well Depth
Max Rate
Units
Oil / Gas Production
Power Production:
Source Name
Source Type
Well Depth
Max Rate
Units
Fossil Fuel
Source Name
Source Type
Well Depth
Max Rate
Units
Nuclear
Other Pwr
Source Name
Source Type
Well Depth
Max Rate
Units
Public Water Supply
Recreational:
Golf Course
Snow Making
Average Day Withdrawal
Units
Maximum Day Withdrawal
Units
NYSDEC Permitted Withdrawal
Units
Other Rec
Other Category
Submitted By:
Title
Date
Water Withdrawal Reporting Form
Section 2 of 6 – Water Use
Calculation Method
If multiple methods are used, choose the one that measures the greatest percentage of water in your system.
E = Estimated
M = Metered readings
W = Flow through a weir
P = Flow through a pipe or pump run times
C = Pump curve calculation
*Units: Must be in
January
February
March
April
May
June
gallons per month
Withdrawn
Transferred /
Imported / Purchased
Consumed
Returned
Diversions In / Out (If
Applicable)
For transferred water or diversions out use a negative (-) sign
*Units: Must be in
July
August
September
October
November
December
gallons per month
Withdrawn
Transferred /
Imported / Purchased
Consumed
Returned
Diversions In / Out (If
Applicable)
Describe location of
returned water:
Water Withdrawal Reporting Form
Section 3 of 6 – Interbasin Diversions & General Maps
Interbasin Diversions
Fill out this section only if water is being transferred between major drainage basins. To determine basin name, go to the DEC Major Drainage Basins
map (http://www.dec.ny.gov/lands/56800.html). Then, enter the basin names below. Describe the locations of originating and receiving sites in the site
description boxes (e.g. Town water intake on Route 12 at northern end of Pleasant Lake to Stony Reservoir near Bear Road).
Originating Major Drainage Basin
Receiving Major Drainage Basin
Basin Name
Basin Name
Originating Site Description
Receiving Site Description
General Map
– A map is required only for Interbasin Diversions (6 NYCRR Part 601.18(e)(2)) and Agricultural Water Withdrawals (6 NYCRR Part
* Note
601.17(b)(2))
Please submit a map showing the location of all withdrawals and any points of return flow.
A paper copy of a USGS map or other high-quality map or an electronically generated map can be faxed, mailed, or emailed. Please ensure that the map
scale is sufficient to be able to see specific locations. Designate all water withdrawal locations on the map. Add markers to locate any related dams,
wetlands, weirs, or diversion structures. Label the name of each point.
Submit your map to DEC in one of the following ways:
• Print and mail to the address in Section 6 of this Form or fax to (518) 402-8290. Include cover letter identifying facility owner.
• Print, scan and email to
awqrsdec@dec.ny.gov
• Copy electronically and email to
awqrsdec@dec.ny.gov
Water Withdrawal Reporting Form
Section 4A of 6 – Public Water Supplies
Public Water Suppliers must answer all questions in this section. If not a Public Water Supply – skip to Section 4B
1. Are all sources of supply including major interconnections equipped with master meters?
Yes
No
2. What percentage of your system is metered?
%
Average age of meters, years:
Range of age of meters, years:
3. How often were customer meters read this past year?
4. Number of water service connections:
Total population served:
5. How many customer meters were recalibrated and/or replaced in the past year?
6. Miles of pipe in water distribution system:
Length of pipe replaced in the past year:
Units:
7. Miles of pipe on which leak detection was performed using sonic listening equipment:
Type of equipment used:
8. How many system-wide water audits were performed in the past year?
9. Residential charge per 1,000 gallons of water: $
10. What percentage of the water withdrawn was not billed to customers?
%
Lost to distribution system leakage?
%
11. Was information about household water saving devices and ways to reduce water use distributed to residential customers?
Yes
No
12. Was water conservation information about promoting recycling and reuse distributed to industrial and commercial customers?
Yes
No
13. Do you have lawn sprinkling time restrictions (e.g., odd/even days) during periods of peak demand?
Yes
No
14. Do you have a plan that takes progressive steps to further reduce outdoor water use during drought conditions with an ordinance to assure
compliance?
Yes
No
If yes, please forward a copy to the address shown in Section 1 of this form.
15. Please review your permit(s) for any specific water conservation conditions and report below on progress made in the past year:
Water Withdrawal Reporting Form
Section 4B of 6 – Non-Public Water Supplies
Non-Public Water Suppliers must answer all questions in this section. For Public Water Supplies – return to Section 4A
1. Are all sources of supply including major interconnections equipped with master meters?
Yes
No
2. How many times were master meters read in the past year?
3. How many times were master meters calibrated in the past year?
4. Are there secondary meters located within the facility or system?
Yes
No
5. Identify other water conservation and efficiency measures currently used in your system (e.g. Best Management Practices such as recycling
process and cooling waters, use of drip irrigation and moisture probes, utilizing storm water runoff and reclaimed wastewater or conducting facility
water audits):