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DNR Temporary Water Appropriations General Permit <br />Report of Water Use Year <br />Less than 50 Million Gallons per Year General Permit 970005 <br />Contact Information <br />Contact Person <br />Company Name <br />Address <br />Phone <br />Purpose Construction Dewatering Hydrostatic Testing of Pipelines or Tanks <br />Landscaping or Dust Control Hydrostatic Testing of Wastewater Ponds <br />Location <br />County Township Range Section(s) <br />Project Name <br />and Description <br />Method of Withdrawal: <br />(describe number of <br />wells, type, and depth) <br />Discharges To: <br />Pumping Pumping report the number of gallons withdrawn for this project during this calendar year by month <br />January July <br />February <br />3Y August <br />March September <br />April October <br />May November <br />June December <br /> Year Total <br />Measurement Method indicate the measurement method used <br />1. Flow Meter . <br />2. Flow Rate Meter with: Totalizer Hour Meter <br />3. Timing Device: Electric meter Hour Meter <br />4. Approved Alternate Method: (attach description) If not already approved, request approval <br />5. Estimated: (attach description) An approved measuring method is required <br />Fees check one <br />Projects pumping less than 15 million gallons per year ^ none <br />Projects pumping 15 million to 50 million gallons per year ^ $50 <br />Return this form after the project is completed, but. no later than February 15th of the year <br />after the appropriation occurs. A report is required for each calendar year of pumping activity. <br />Make checks payable to DNR Waters, and mail to: <br />DNR Waters <br />500 Lafayette Rd Box 32 <br />St. Paul, MN 55155-4032 <br />If you have any questions concerning reporting, <br />please call (651)296-0435. <br />You can also leave a message after hours. <br />Signature Date <br />