ds-02 03/08
OSE File Number:
NEW MEXICO OFFICE OF THE STATE ENGINEER
PROOF OF COMPLETION OF WORKS – DAM
DAM OWNER'S CERTIFICATE
State of
)
) ss.
)
County of
I,
, on behalf of
, County of
certify that I am the owner of
located on or divert water from
, State of
, being first duly sworn, do hereby
Dam and holder of a permit to Construct and Operate a Dam
a tributary of
, in the County of
, for
purposes; that Formal Application for said permit together with necessary reports, drawings and
specifications was received and filed in the Office of the State Engineer of New Mexico under
Permit No.
; that said application, reports, drawings and specifications were accepted by the
State Engineer on the
day of
, 20
; that the works necessary to accomplish the
construction and operation of the dam in accordance with the terms of said permit have been
completed; that the following statement of facts is submitted in proof of the completion of said
dam; and that said statement and each and all of the items contained therein are true to the best
of my knowledge and belief.
_______________________________________
(Dam Owner’s Signature)
___________________________
(Date)
Subscribed and sworn to before me this _______ day of __________________, 20___.
___________________________________.
Notary Public
My commission expires ________________________ (SEAL)
STATEMENT
1. DAM OWNER:
Name:
Work Phone:
Contact:
Home Phone:
Address:
City:
State:
Zip:
OSE File Number:
NEW MEXICO OFFICE OF THE STATE ENGINEER
PROOF OF COMPLETION OF WORKS – DAM
2. HAZARD POTENTIAL CLASSIFICATION:
3. LOCATION:
A.
1/4 of the
in
or X =
1/4 of the
1/4 Section:
Township:
County.
feet, Y =
feet, N.M. State Plane Coordinate System
Zone Datum of
in the
Grant.
B. Latitude in decimal degrees:
Longitude in decimal degrees:
C. On land owned by:
D. Source of Water Supply:
a. Name of Surface Watercourse:
, Tributary of
b. Name of Groundwater Basin:
c. Name of Ditch or Spring (Off Channel Dams):
E. Distance to the nearest downstream City/Town (miles):
4. PROPERTIES OF DAM AND RESERVOIR:
A. Dam length:
feet
B. Crest width:
feet
C. Base width:
feet
D. Dam height:
feet
E. Structural height:
feet
F. Elevation of the dam crest:
G. Slope of upstream face:
horizontal to 1 vertical
H. Slope of downstream face:
I.
Volume of dam:
J.
Type of dam:
feet
horizontal to 1 vertical
cubic yards
K. Dead storage capacity:
acre-feet
L. Reservoir storage capacity:
acre-feet
M. Maximum storage capacity:
acre-feet
N. Spillway or inflow design flood water level elevation:
feet
O. Reservoir surface area at reservoir storage capacity:
acres
Range:
N.M.P.M.
OSE File Number:
NEW MEXICO OFFICE OF THE STATE ENGINEER
PROOF OF COMPLETION OF WORKS – DAM
4. PROPERTIES OF DAM AND RESERVOIR continued:
P. Stage/Area/Storage capacity (elevations at the outlet invert, spillway and dam crest plus others):
Elevation or depth
above outlet (Feet)
Area of Water
Surface, (Acres)
Storage Capacity
(Acre Feet)
5. PROPERTIES OF OUTLET CONDUIT:
A. Outlet conduit is:
(give size and material)
B. Length of conduit:
feet
C. Slope of conduit:
percent
D. Manning coefficient:
E. Maximum discharge capacity (at crest of dam):
cubic feet/second
F. Elevation of upstream end of the invert of the outlet conduit:
feet
G. Size, Type and Number of Gates:
H. Time to empty the reservoir:
hours or
days
6. PROPERTIES OF SPILLWAY:
A. Spillway is:
(give type and material)
B. Location:
C. Spillway crest elevation:
D. Freeboard:
feet
feet
E. Discharge coefficients:
F. Effective length:
(dependent on type)
feet
G. Discharge capacity (at the spillway design flood elevation):
H. Maximum discharge capacity (at the dam crest):
I.
Residual freeboard:
feet
cubic feet/second
cubic feet/second
OSE File Number:
NEW MEXICO OFFICE OF THE STATE ENGINEER
PROOF OF COMPLETION OF WORKS – DAM
7. CONSTRUCTION OF WORKS WAS COMPLETED:
8. ADDITIONAL STATEMENTS OR EXPLANATIONS:
ENGINEER'S CERTIFICATE
State of
County of
)
) ss.
)
I,
, of
, state that I am the engineer approved to supervise construction; 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 constructed in accordance with the construction
drawings and specifications accepted by the state engineer and are now in a satisfactory
condition for acceptance.
Signed:
_______________________________
Date:
_______________________________
(Engineer’s Seal)
License No.: _______________________________
INSTRUCTIONS
This form shall be filed with original signatures and filing fee of $25.00. The form shall be mailed to the
attention of the OSE Dam Safety Bureau, P.O. Box 25102, Santa Fe, New Mexico 87504.
Hit “F1” key for additional instructions for each cell. Cell sizes are limited.
Dam Owner’s Certification: Information and notarized signature of the dam owner are required.
Section 1 All information is required.
Section 2 Hazard Potential Classification of Low, Significant or High. Refer to 19.25.12.10 NMAC
Section 3 Information for Parts A through E required.
Section 4 All information is required if applicable.
Section 5 All information is required if applicable.
Section 6 All information is required if applicable.
Section 7 Information is required.
Section 8 Fill in blanks if additional information is necessary.
Engineer’s Certification: Information required. Print name and company, sign, stamp and date.