This application is for a
Pilot Project
Demonstration Project
Full-scale Project
For fees, see State Engineer website: http://www.ose.state.nm.us/
What type of recharge to the aquifer?
Direct Injection
Infiltration
Associated OSE File Number(s):
_________________________________
_________________________________
_________________________________
Has a pre-application meeting been held with OSE? Yes No Date of meeting:______________________
Has a pre-application project proposal been submitted to OSE? Yes No Date submitted to OSE:______________________
Has the application been advertised? Yes No Date: ______________________ Attach a copy of the advertised notice.
Is a capability report, as required, included with this application? Yes No
Has a copy of the Notice of Intent to Discharge been filed with New Mexico Environment Department? Yes No
Is a stamped copy attached to this application? Yes No
Is a discharge permit approval included with this application? Yes No NMED Permit Nr:_____________________
Notes?
Proposed duration for this project: Requested Start Date:____________________Requested End Date:____________________
1. APPLICANT AND CONSULTANT (REQUIRED) NOTE: WATER-RIGHT OWNER MUST BE LISTED AS AN APPLICANT.
Applicant Name:
Consultant’s Company Name:
Contact or Agent: check here if Agent
Mailing Address:
Contact
Mailing Address:
City: City:
State: Zip Code: State: Zip Code:
Office Phone:
Cell Phone:
Office Phone:
Cell Phone:
E-mail (optional): E-mail (optional):
2. CURRENT PURPOSE OF USE (Purpose of use for recovered water must be the same as the original diverted water.)
Domestic Livestock Irrigation Municipal Industrial Commercial
Other Use: Describe a specific use, if applicable (i.e. flood control etc):
FOR OSE INTERNAL USE
File Number:
Application for Permit, Form wr-USR, 9/16/15
Trn Number:
Page 1 of 9

3. CURRENT PLACE OF USE OF WATER PLANNED FOR STORAGE
(Place of use for recovered water must be the same place of use as the original diverted water, except by other permit.)
4. NAME OF THE DECLARED UNDERGROUND WATER BASIN IN WHICH THE PROJECT WILL BE LOCATED
5. AMOUNT OF WATER
Maximum injection or infiltration rate (afy): ______________
Maximum recovery rate (afy): ______________
Maximum total annual storage (ac-ft): ______________
Additional comments:
6. SUMMARIZE THE SHORT-TERM PRIMARY OBJECTIVES OF THIS PROJECT? (Attach additional pages as necessary.)
7. SUMMARIZE THE PLAN OF OPERATION AND CAPACITY OF THE PROJECT?
(Attach additional pages/drawings/maps as necessary.)
8. BRIEFLY DESCRIBE THE TOTAL PROJECT AREA OF HYDROLOGIC EFFECT (Attach additional pages/maps as necessary.)
9. SUMMARIZE THE MONITORING PROGRAM(S) THAT WILL BE EMPLOYED FOR THIS PROJECT.
(Attach additional pages/drawings as necessary.)
10. WHAT IS THE LONG-RANGE PLAN FOR THIS USR PROJECT IF IT PROGRESSES TO FULL-SCALE.
DESCRIBE PHASES FOR FULL IMPLEMENTATION? (Attach additional pages and refer to appropriate section in the
Capability Report, as necessary.)
FOR OSE INTERNAL USE
Application for Permit, Form wr-USR, 9/16/15
File Number: Trn Number:
Page 2 of 9

11. CURRENT or MOVE-FROM POINT(S) OF DIVERSION (POD) or OTHER SOURCES OF WATER
OSE File Number:
Surface POD OR Ground Water POD (Well) OR Reclaimed Water
Name of ditch, acequia, or spring:
Stream or water course: Tributary of:
POD Location Required: Coordinate location must be reported in NM State Plane (NAD 83), UTM (NAD 83), or
Latitude/Longitude (Lat/Long - WGS84). District II (Roswell) & District VII (Cimarron) customers, provide a PLSS location in addition to above.
NM State Plane (NAD83) (Feet)
NM West Zone
NM East Zone
NM Central Zone
UTM (NAD83) (Meters)
Zone 12N
Zone 13N
Lat/Long (WGS84) (to the nearest
1/10 th of second)
POD Number (if known):
X or Easting or
Longitude:
Y or Northing or Latitude:
Provide if known:
-Public Land Survey System (PLSS)
(Quarters or Halves , Section, Township, Range) OR
- Hydrographic Survey Map & Tract; OR
- Lot, Block & Subdivision; OR
- Land Grant Name
NOTE: If more PODs need to be described, attach additional pages as necessary.
Additional point(s) of diversion descriptions are attached: Yes No If yes, how many__ __
Point(s) of diversion is on land owned by:
Other description relating point(s) of diversion to common landmarks, streets, or other:
12. DESCRIBE THE MODEL THAT WAS USED TO DETERMINE THE AREA OF HYDROLOGIC EFFECT. (Attach additional pages and reference materials as needed.)
13. IDENTIFY MODEL CHARACTERISTICS SUCH AS SIZE, LAYERS, GRID SPACING, RECHARGE BOUNDARIES, DISCHARGE
BOUNDARIES, ETC. (Attach additional pages and reference materials as needed.)
FOR OSE INTERNAL USE
File Number:
Application for Permit, Form wr-USR, 9/16/15
Trn Number:
Page 3 of 9

14. DESCRIBE THE RANGE OF VALUES FOR THE HYDROLOGIC PARAMETERS USED IN THE MODEL. (Attach additional pages and reference materials as needed.)
15. PROPOSED POINT(S) OF INFILTRATION or INJECTION (POI)
OSE File Number:
Surface Infiltration OR Ground Water Injection (Well)
Name of ditch, arroyo, acequia, or spring:
Stream or water course: Tributary of:
Does this application propose new infrastructure (diversion dam, storage dam, main canal, pipeline, injection well, etc.) for a point of infiltration or injection? Yes No
Notes:
POI Location Required: Coordinate location must be reported in NM State Plane (NAD 83), UTM (NAD 83), or
Latitude/Longitude (Lat/Long - WGS84). District II (Roswell) & District VII (Cimarron) customers, provide a PLSS location in addition to above.
NM State Plane (NAD83) (Feet)
NM West Zone
NM East Zone
NM Central Zone
UTM (NAD83) (Meters)
Zone 12N
Zone 13N
Lat/Long (WGS84) (to the nearest
1/10 th of second)
POD/Well Number
(if known):
X or Easting or
Longitude:
Y or Northing or Latitude:
Provide, if known:
-Public Land Survey System (PLSS)
(Quarters or Halves , Section, Township, Range)
NOTE: If more POIs need to be described, attach additional pages as necessary.
Additional points of infiltration/injection descriptions are attached: Yes No If yes, how many__ __
Point(s) of infiltration/injection is on land owned by:
Other description relating point(s) of infiltration/injection to common landmarks, streets, or other:
FOR OSE INTERNAL USE
File Number:
Application for Permit, Form wr-USR, 9/16/15
Trn Number:
Page 4 of 9

16. DESCRIBE HOW THE INFILTRATION/INJECTION FACILITIES WILL BE OPERATED AND MAINTAINED, AND INCLUDE
OPERATING PARAMETERS. (Attach additional pages/drawings and reference materials as needed. Refer to the appropriate section of the Capability Report.)
17. PROPOSED POINT(S) OF RECOVERY (POR)
OSE File Number:
Does this application propose a new point of recovery well? Yes No
POR Location Required: Coordinate location must be reported in NM State Plane (NAD 83), UTM (NAD 83), or
Latitude/Longitude (Lat/Long - WGS84). District II (Roswell) & District VII (Cimarron) customers, provide a PLSS location in addition to above.
NM State Plane (NAD83) (Feet)
NM West Zone
NM East Zone
NM Central Zone
UTM (NAD83) (Meters)
Zone 12N
Zone 13N
Lat/Long (WGS84) (to the nearest
1/10 th of second)
POD Number (if known):
X or Easting or
Longitude:
Y or Northing or Latitude:
Provide if known:
-Public Land Survey System (PLSS)
(Quarters or Halves , Section, Township, Range) OR
- Hydrographic Survey Map & Tract; OR
- Lot, Block & Subdivision; OR
- Land Grant Name
NOTE: If more PORs need to be described, attach additional pages as necessary.
Additional points of recovery descriptions are attached: Yes No If yes, how many__ __
Point(s) of recovery is on land owned by:
Other description relating point(s) of recovery to common landmarks, streets, or other:
18. GENERALLY DESCRIBE THE METHOD AND EQUIPMENT FOR RECOVERY.
(Attach additional technical pages/drawings/maps as necessary.)
FOR OSE INTERNAL USE
File Number:
Application for Permit, Form wr-USR, 9/16/15
Trn Number:
Page 5 of 9

19. DESCRIBE HOW THE STORED WATER RECOVERY FACILITIES WILL BE OPERATED AND MAINTAINED, AND INCLUDE
OPERATING PARAMETERS. (Attach additional pages/drawings and reference materials as needed. Refer to the appropriate section in the Capability Report.)
20. WHAT METHODS WILL BE USED TO MONITOR WATER LEVELS IN THE RECOVERY AREA OF HYDROLOGIC EFFECT?
INCLUDE FREQUENCY OF MEASUREMENT AT EACH WELL. (Attach additional pages and refer to appropriate section in the Capability Report, as necessary.)
21. DESCRIBE SPECIFIC ITEMS OF NOTE OF THE AREA AND HYDROGEOLOGIC CHARACTERIZATION OF THE AREAS OF
HYDROLOGIC EFFECT OF THE DIVERSION, INFILTRATION/INJECTION, AND STORAGE & RECOVERY. IN SEPARATE
DOCUMENTS, INCLUDE A TOPOGRAPHIC MAP (AND TABLES, IF NECESSARY) SHOWING LOCATIONS OF SURFACE
WATER BODIES, CANALS AND DITCHES, WELLS, AND OTHER WATER FEATURES THAT MAY BE AFFECTED BY THE
PROPOSED USR PROJECT. INCLUDE INFORMATION ON HAZARDOUS WASTE OR OTHER CONTAMINATION SITES OF
POTENTIAL ENVIRONMENTAL IMPACT. (Refer to the appropriate section of the Capability Report.)
22. LIST ALL MONITORING WELLS THAT WILL BE EMPLOYED
Monitoring Wells Locations Required: Coordinate location must be reported in NM State Plane (NAD 83), UTM (NAD 83), or
Latitude/Longitude (Lat/Long - WGS84). District II (Roswell) & District VII (Cimarron) customers, provide a PLSS location in addition to above.
NM State Plane (NAD83) (Feet)
NM West Zone
NM East Zone
NM Central Zone
UTM (NAD83) (Meters)
Zone 12N
Zone 13N
Lat/Long (WGS84) (to the nearest
1/10 th of second)
Provide if known:
OSE File Number and
POD Number (if known):
X or Easting or
Longitude:
Y or Northing or Latitude:
-Public Land Survey System (PLSS)
(Quarters or Halves , Section, Township, Range) OR
- Hydrographic Survey Map & Tract; OR
- Lot, Block & Subdivision; OR
- Land Grant Name
- Land owner where monitoring well is located
NOTE: If more monitoring wells need to be described, attach additional pages as necessary.
Additional monitoring wells descriptions are attached: Yes No If yes, how many__ __
FOR OSE INTERNAL USE
File Number:
Application for Permit, Form wr-USR, 9/16/15
Trn Number:
Page 6 of 9

23. DESCRIBE ANY POSSIBLE IMPAIRMENT THAT MIGHT OCCUR TO EXISTING VALID WATER RIGHTS OWNERS IN THE
AREAS OF HYDROLOGIC EFFECT FOR THE DIVERSION, INJECTION/INFILTRATION, AND RECOVERY OF STORED WATER
UNDER THIS USR PROJECT. (Attach additional pages and refer to appropriate section in the Capability Report, as necessary.)
24. DESCRIBE MITIGATION MEASURES THAT WILL BE EMPLOYED TO PREVENT IMPAIRMENT FROM THIS PROJECT.
(Attach additional pages as necessary.)
25. LIST OTHER (not previously listed as monitoring wells for this project) PERMITTED AND EXISTING WELLS IN THE
INJECTION/INFILTRATION AND RECOVERY AREA(S) OF HYDROLOGIC EFFECT
POD/Well Locations Required: Coordinate location must be reported in NM State Plane (NAD 83), UTM (NAD 83), or
Latitude/Longitude (Lat/Long - WGS84). District II (Roswell) & District VII (Cimarron) customers, provide a PLSS location in addition to above.
NM State Plane (NAD83) (Feet)
NM West Zone
NM East Zone
NM Central Zone
UTM (NAD83) (Meters)
Zone 12N
Zone 13N
Lat/Long (WGS84) (to the nearest
1/10 th of second)
OSE File Number and
POD Number (if known):
X or Easting or
Longitude:
Y or Northing or Latitude:
Provide if known:
-Public Land Survey System (PLSS)
(Quarters or Halves , Section, Township, Range) OR
- Hydrographic Survey Map & Tract; OR
- Lot, Block & Subdivision; OR
- Land Grant Name
- Well Owner
NOTE: If more PODs need to be described, attach additional pages as necessary.
Additional PODs Descriptions are attached: Yes No If yes, how many__ __
FOR OSE INTERNAL USE
File Number:
Application for Permit, Form wr-USR, 9/16/15
Trn Number:
Page 7 of 9

26. DESCRIBE ANY POTENTIAL CONTAMINATION OR ECOLOGICAL CONCERNS OR IMPACTS WITHIN THE
INJECTION/INFILTRATION AND RECOVERY AREA(S) OF HYDROLOGI C EFFECT. (Attach additional pages and refer to appropriate section in the Capability Report, as necessary.)
27. DESCRIBE ALL ENVIRONMENTAL OR WATER REMEDIATIATION PROJECTS WITHIN THE DIVERSION,
INJECTION/INFILTRATION, AND RECOVERY AREA(S) OF HYDROLOGI C EFFECT.. (Attach additional pages and refer to appropriate section in the Capability Report, as necessary.)
28. ADDITIONAL STATEMENTS OR EXPLANATIONS
FOR OSE INTERNAL USE
File Number:
Application for Permit, Form wr-USR, 9/16/15
Trn Number:
Page 8 of 9

ACKNOWLEDGEMENT
I, We (name of applicant(s)),
Print Name(s) affirm that the foregoing statements are true to the best of (my, our) knowledge and belief.
___________________________________________________
Applicant Signature
_________________________________________________
Applicant Signature
ACTION OF THE STATE ENGINEER
This application is: approved partially approved denied provided it is not exercised to the detriment of any others having existing rights, and is not contrary to the conservation of water in New
Mexico nor detrimental to the public welfare and further subject to the attached conditions of approval.
Witness my hand and seal this day of 20 , for the State Engineer,
______________________________________________________, State Engineer
By:
Signature
Title:
Print
Printed Name
FOR OSE INTERNAL USE
File Number:
Application for Permit, Form wr-USR, 9/16/15
Trn Number:
Page 9 of 9