Download the printable PDF version of this form.
K.S.A. 82a-1030 (states in part):
By authority of K.S.A. 82a-1030: the District will be assessing a water user charge on every non-domestic, authorized well within the District. The charge will be assessed on the entire amount of water authorized by the water right covering that well. UNLESS a verified claim is filed substantiating less water actually pumped during the water use year. Whenever a person shows by the submission to the board of a verified claim and any supportive data which may be required by the board that such person's actual annual groundwater withdrawal is in a lesser amount than that allocated by the water right of such person, the board shall assess such annual charge against such person on the amount of water shown to be withdrawn by the verified claim. Any such claim shall be submitted by April 1 of the year in which such annual charge is to be assessed. The District will accept metered values, enrollment in CRP when no water is pumped or verified claims showing that the well has not been completed or pump installed.
Please note that this form does not replace the annual water use report required by the Division of Water Resources, State Board of Agriculture, Manhattan, KS.
Must be completed and returned to GMD3 by April 1 of the year charge is to be assessed.
Parcel ID NO. (16 digit CAMA No.):
Water Right Number or Vested Right Number:
Zip code (required)
Permanent Flow Meter
Well in CRP or WRCP
Units Used (Gallons/Acre Feet/etc.)
If this claim is to show enrollment in CRP or WRCP or that the well was not completed, or was dismissed, please enter that information instead of meter data.
The Undersigned, of lawful age, states that he / she has reviewed the above report and affirms the contents contained herein as factual and accurate.
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