File Number: _______________
(For OSE Use Only)
NEW MEXICO OFFICE OF THE STATE ENGINEER
PROOF OF COMPLETION OF WORKS
(SURFACE WATERS)
1. PERMITTEE
Name: _________________________________________ Work Phone: ____________
Contact: _________________________________________ Home Phone: ____________
Address: _________________________________________
_________________________________________
City: _________________________________________ State: __ Zip: __________
2. POINT OF DIVERSION (A, B, C, or D required, E or F if known)
A. ____1/4 ____1/4 ____1/4 Section:____ Township:____ Range:____ N.M.P.M.
in ______________________________________________________________ County.
B. X =_____________ feet, Y = _________________ feet, N.M. Coordinate System
__________ Zone in the ___________________________________________ Grant.
U.S.G.S. Quad Map _____________
C. Latitude: ______d _____m _________s
Longitude: ______d _____m _________s
D. East __________ (m), North __________ (m), UTM Zone 13, NAD __ (27 or 83)
E. Tract No. _____, Map No. _____ of the _______________ Hydrographic Survey
F. Lot No. _____, Block No. _____ of Unit/Tract _____________________ of the
____________________ Subdivision recorded in ____________________ County.
G. Other: __________________________________________________________________
H. Give State Engineer File Number if existing well:
______________________
I. On land owned by (required): ____________________________________________
J. Source of surface water supply:
a. Name of ditch, acequia, or spring: ___________________________________
b. Stream or water course: ______________________________________________
c. Tributary of: ________________________________________________________
3. CONSTRUCTED WORKS CONSIST OF:
(Enumerate Diversion dams, main canals, headgates, pipelines, flumes,
reservoirs, laterals, etc.)_________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__________________________Do Not Write Below This Line________________________
File Number: _______________
Form: wr-22
Trn Number: _______________
page 1 of 4
File Number: _______________
(For OSE Use Only)
NEW MEXICO OFFICE OF THE STATE ENGINEER
PROOF OF COMPLETION OF WORKS
(SURFACE WATERS)
4. DIVERSION DAM (if applicable)
The diversion dam is constructed of _______________________________________;
Crest length ________ feet; Crest width _________ feet;
Height above stream bed ________ feet; Depth below stream bed ________ feet;
Side slopes of ________ horizontal to 1 (one) vertical on upstream face
And ________ horizontal to 1 (one) vertical on downstream face;
And contains about ________ cubic yards of material.
5. HYDRAULIC PROPERTIES OF MAIN CANAL OR PIPELINE (if applicable)
Name of ditch ____________________________________________________________ ;
Bottom width ________ feet;
Depth of water at full operating capacity _________ feet;
Side slopes _________ horizontal to 1 (one) vertical;
Diameter (pipe line or circular flume) ________ feet;
Type of pipe line _________________________________________________________;
Slope ________ feet per 1000 feet; Capacity ________ cubic feet per second;
Length of canal or pipeline _________ feet.
__________________________Do Not Write Below This Line________________________
File Number: _______________
Form: wr-22
Trn Number: _______________
page 2 of 4
File Number: _______________
(For OSE Use Only)
NEW MEXICO OFFICE OF THE STATE ENGINEER
PROOF OF COMPLETION OF WORKS
(SURFACE WATERS)
6. HYDRAULIC PROPERTIES - STORAGE DAM (if applicable)
Maximum storage capacity _________ acre feet;
Maximum height above foundation _________ feet; length of crest _______ feet;
Maximum width at base ________ feet; Crest width _________ feet;
Slope of upstream face _____________________ horizontal to 1 (one) vertical;
Slope of downstream face ____________________ horizontal to 1 (one) vertical;
Elevation of crest of dam _____ feet; Elevation of spillway crest _____ feet;
Elevation of flow line of outlet conduit ________ feet;
Freeboard (above high water line at maximum spill) ________ feet;
Width of spillway ________ feet;
Discharge capacity of spillway ________ cubic feet per second;
Location of spillway: _____________________________________________________;
Cross-sectional area at maximum flow: ________ square feet;
Size and character of outlet conduit _______________________________________
___________________________________________________________________________;
Type of dam, construction material, etc. ___________________________________
____________________________________________________________________________
____________________________________________________________________________
Elevation or (feet)
depth above outlet
____________________
____________________
____________________
____________________
____________________
Area of Water Storage Capacity
Surface, (Acres) (Acre Feet)
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Remarks
_____________________
_____________________
_____________________
_____________________
_____________________
7. CONSTRUCTION OF WORKS WAS COMPLETED: ____________
(mm/dd/year)
8. ADDITIONAL STATEMENTS OR EXPLANATIONS:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__________________________Do Not Write Below This Line________________________
File Number: _______________
Form: wr-22
Trn Number: _______________
page 3 of 4
File Number: _______________
(For OSE Use Only)
NEW MEXICO OFFICE OF THE STATE ENGINEER
PROOF OF COMPLETION OF WORKS
(SURFACE WATERS)
ENGINEER'S CERTIFICATE
State of New Mexico
County of ______________________________
I,_________________________ state that I am a qualified registered
professional engineer, that I have inspected the works as above set forth
and find them to be completed in accordance with the foregoing statement
of facts; that they are properly and safely constructed and are now in a
satisfactory conedition for acceptance.
(Engineer’s Seal)
Signed: _______________________________
License No.: _______________________________
_______________________________________________________________________________
ACKNOWLEDGEMENT
(I, We) ____________________________________________________ affirm that the
(Please Print)
foregoing statements are true to the best of (my, our) knowledge and belief.
_____________________________________ _____________________________________.
Permittee Signature
Permittee Signature
__________________________Do Not Write Below This Line________________________
File Number: _______________
Form: wr-22
Trn Number: _______________
page 4 of 4