Water Withdrawal Reporting Form

Introduction: This online form allows you to report your water usage electronically. For some farms, reporting is required by law. All fields are required unless specified. A SEPARATE FORM MUST FILLED OUT FOR EACH INDIVIDUAL WATER SOURCE

CONVERSIONS: 1 Acre-inch = 27,154 gallons 1 Acre-foot = 325,851 gallons
FARM CONTACT INFORMATION
Date
First Name
Last Name
Company/Farm Name
Street/Mailing Address
City/town
County
State
Zip
E-mail	(optional)
Phone	- -
Fax	- - (optional)
WATER SOURCE INFORMATION
Named Source of Water. (If no legal name, provide a name, eg. Bob's Pond.)
Type of water source used for irrigation.	Well River, Stream or Brook Natural Pond or Lake Manmade Pond Other (Please Describe)
If source is a well, give approximate distance from well to closest surface water source.	Feet
Location of Source, eg. how you would get there.
Location of Discharge.
HUC Watershed Code	(optional)
WATER USE REPORTING
Weeks	Actual total volume of water used in the week (Calculated use acceptable) (in gallons)
Week 1 (first week in October)
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Week 9
Week 10
Week 11
Week 12
Week 13
Week 14
Week 15
Week 16
Week 17
Week 18
Week 19
Week 20
Week 21
Week 22
Week 23
Week 24
Week 25
Week 26
Week 27
Week 28
Week 29
Week 30
Week 31
Week 32
Week 32
Week 34
Week 35
Week 36
Week 37
Week 38
Week 39
Week 40
Week 41
Week 42
Week 43
Week 44
Week 45
Week 46
Week 47
Week 48
Week 49
Week 50
Week 51
Week 52

P!!lease Print this page out for your records, before you submit

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Maine Agricultural Water Management Board

Water Withdrawal Reporting Form

FARM CONTACT INFORMATION

WATER SOURCE INFORMATION

WATER USE REPORTING