Form 646 - Geothermal Heating/cooling Notice Of Completion - 2011

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Form No. 646 R10/23/2011
GEOTHERMAL HEATING / COOLING
NOTICE OF COMPLETION
FOR DEPARTMENT USE ONLY
Notice No. _________________ Basin _________________
Use this form for completed groundwater
Priority Date ________________ Time ___________AM - PM
developments where the water has been put to use for
Rec'd By
_______________________________________
non-consumptive geothermal heating or cooling
Fee Rec'd $ ____________
Check No. _____________
purposes with a maximum use of 350 GPM.
Deposit Receipt # __________________________________
Payor (if different from name(s) listed in item 1 below)
__________________________________________________
Incomplete forms will be returned.
Refund $
______________
Date __________________
Deficiency Letter Sent ________________________________
Filing Fee $250.00
Your priority is determined by the date of filing. If it is determined this form was improperly filed, your priority date may be changed.
ANSWER THE QUESTIONS LISTED BELOW TO DETERMINE IF YOU CAN FILE YOUR WATER USE ON THIS FORM.
Yes
No
Is the appropriation located outside the boundaries of a controlled groundwater area?
Yes
No
Is the maximum appropriation 350 gallons per minute (GPM) or less?
Yes
No
Is all water that is extracted returned without delay into the same source aquifer?
Yes
No
Is the distance between the extraction well and both the nearest existing well and any hydraulically connected surface
water source more than twice the distance between the extraction and injection well?
If the answers to all questions above are “yes,” you can use this form. If any answer above is “no,” contact the regional office.
1.
NAME
____________________________________________________________________________________________________________
MAILING ADDRESS
____________________________________________________________________________________________________
CITY _________________________________
STATE
________________________
ZIP______________________________
WORK PHONE
_______________________
HOME PHONE____________________
CELL PHONE_____________________
2.
DIVERSION USED TO OBTAIN / RETURN GROUNDWATER
Wells – Attach well logs for all extraction and injection wells.
Developed Springs (excavation performed at the spring location) – Attach well log for injection well if used. If injection well not used, describe
injection apparatus showing that water is injected into the same aquifer from which it is extracted.
_________________________________
__________________________________________________________________________________________________________________
______________________________________________________________________________________________________________
3.
FLOW RATE USED ____________ GPM
4.
PERIOD OF USE
Year round use?
Yes
No
If no, from __________ to __________, inclusive each year.
5.
EXTRACTION LOCATION
Latitude ____________________
Longitude ____________________
_____1/4 _____1/4 _____1/4 Section _____ Twp _____N / S Rge _____E /W County __________________________________________________
Lot _______ Block _______Tract No. _______
Subdivision Name ____________________________________________________________
Government Lot No. _____________________________
COS No.
__________________________________________________
Street or Road Address, including City, State & Zip Code of the Development __________________________________________________________
6.
INJECTION LOCATION
Latitude ____________________
Longitude ____________________
_____1/4 _____1/4 _____1/4 Section _____ Twp _____N / S Rge _____E /W County __________________________________________________
Lot _______ Block _______Tract No. _______
Subdivision Name ____________________________________________________________
Government Lot No. _____________________________
COS No.
__________________________________________________
7.
DISTANCE FROM POINT OF EXTRACTION TO POINT OF INJECTION
_______________ feet
8.
DISTANCE FROM POINT OF EXTRACTION TO BOTH NEAREST EXISTING WELL AND HYDRAULICALLY CONNECTED SURFACE WATER
Distance to well _______________ feet
Distance to hydraulically connected surface water source _______________ feet
9.
PLACE OF USE - Enter the 17 digit geocode applicable to the place of use legal land description. ________________________________________ If
there are multiple places of use, attach additional sheets and list the geocode for each legal land description.
Geocodes can be found in county records, at , and on tax assessment notices.
Is the place where water is used the same as the point of diversion?
Yes
No
If no, enter the place of use land description below. Attach additional sheets if necessary.
_____1/4 _____1/4 _____1/4 Section _____ Twp _____N/S Rge _____E/W County _______________________________________________
Lot _______ Block _______Tract No. _______
Subdivision Name ___________________________________________________________
Government Lot No. _________________________
COS No. __________________________________________________________________
Street or Road Address, including City, State & Zip Code of the Place of Use _________________________________________________________
10.
MAP – Map standards must be followed pursuant to ARM 36.12.111(1) through (3)
Attach a map showing points of extraction/injection, nearest existing well, and nearest hydraulically connected surface water source. Label all distances.
11.
AFFIDAVIT OF OWNERSHIP OR WRITTEN CONSENT
I have possessory interest in the property where the water has been put to beneficial use and I have the exclusive property rights
in the ground water development works OR I have attached written consent of the person owning the ground water development
works and/or written notification to the land owner pursuant to MCA 85-2-306(1).
The statements appearing here are to the best of my knowledge true and correct.
Appropriator's Signature
________________________________________________________
Date: ___________________
Appropriator's Signature
________________________________________________________
Date: ___________________
Go to web site
to learn additional information about the use of this form.

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