Mailing Information:

1. Name of Entity:
   
2. Type of Entity:   Association Private Company (ie, LLC, Corporation, Non-Profit) Irrigation District Tribal State Agency Other
      If Other, please list:
   
3. Contact Person: Email: 
             Address: Phone:
          City/Town:  State: Zip Code: County:
     Water Division: 1 2 3 4
   

Irrigation Surface Water Source(s):

1. Surface Water Source name(s) (eg. Barlow Ditch, Boysen Reservoir, etc):
   

In the following three tables, please complete the table(s) according to the size of the facility or facilities within your district. This may mean completing more than one table for your district/entity. Please estimate the capacity, length, condition (Very Good, Good, Fair, Poor, or Very Poor), and age of conveyances and structures.

Large Conveyance Facilities: 200 cfs or larger

Medium Conveyance Facilities: 100-199 cfs

Small Conveyance Facilities: <100 cfs

Irrigation Groundwater Source(s)

1. Total number of wells serving more than one user:
   
2. Total production capacity of wells serving more than one user (gpm):
   
3. Average depth of wells:
   

Dam/Reservoir Source(s)

Dam/Reservoir Name	Storage Capacity (AF)	Age	Condition	Year of Last Major Rehab
		<25 Years 25 - 50 Years 51 - 75 Years >75 Years	Very Good Good Fair Poor Very Poor
		<25 Years 25 - 50 Years 51 - 75 Years >75 Years	Very Good Good Fair Poor Very Poor
		<25 Years 25 - 50 Years 51 - 75 Years >75 Years	Very Good Good Fair Poor Very Poor
		<25 Years 25 - 50 Years 51 - 75 Years >75 Years	Very Good Good Fair Poor Very Poor
		<25 Years 25 - 50 Years 51 - 75 Years >75 Years	Very Good Good Fair Poor Very Poor

Service Area

1. Service Area Irrigated Acres	Acres Flood Irrigated	Acres Sprinkler Irrigated	Number of Water Users/Operators

2. Crop Type	Acres
   Alfalfa Beans Beets Corn Grains Native/Wild Hay
   Alfalfa Beans Beets Corn Grains Native/Wild Hay
   Alfalfa Beans Beets Corn Grains Native/Wild Hay
   Other 1
   Other 2

3. Do you provide water through your system to another, separate entity?
   
4. Regarding #3, who, and how much water? (cfs or acre-feet):
   

Financial - Assessment

1. How are users assessed for water and what is the assessment? (Assessment by shares, per acre, by water amount?)
   
   
2. Are users assessed for reservoir storage water? (If the answer is no, go to the Financial - Budget section) Yes No

Financial - Reservoir Assessment

1. How are users assessed for reservoir storage water and what is the assessment? (Shares, acre-feet, or other? Please explain.)
    
   
2. Provide a breakdown of the annual assessment for reservoir storage (O&M, emergency fund, loan payment, etc.)
    
   
3. What is the sum total of assessments collected for the reservoir storage facility annually?
    
   
4. How is the reservoir storage water assessment collected? (Property or ad valorem taxes, other)
    
   

Financial - Budget

1. What is the approximate annual budget for your entity?
   
   
2. Do you have a source of income other than assessments on water users? Yes No
   If yes, how much per year?
   
3. How many employees do you have? Full time Seasonal
   
4. Do you have existing debt? Yes No
   If yes: Amount of debt Date of debt retirement
   

Operational Issues

1. Do you have a board of directors? Yes No
   
2. How are operational decisions made for your entity? (Membership meetings, board of directors, mail votes, etc.)
    
   
3. Do you have water conservation measures in place? Please describe.
    
   
4. Does the operation of your system result in return flows upon which other users are dependent? Yes No
     Please Describe?
   
5. Please estimate the post diversion conveyance losses in your system %
   
6. Does the operation of your system provide significant wildlife habitat benefits? Please describe.
    
   

Planned Projects
Please list your entities' top 3-5 planned projects:

Name	Timeframe	Cost ($)	State Funds? (Estimate $ amount)
	0-5 Years 6-10 Years 11-15 Years 16-20 Years 21-25 Years >25 Years
	0-5 Years 6-10 Years 11-15 Years 16-20 Years 21-25 Years >25 Years
	0-5 Years 6-10 Years 11-15 Years 16-20 Years 21-25 Years >25 Years
	0-5 Years 6-10 Years 11-15 Years 16-20 Years 21-25 Years >25 Years
	0-5 Years 6-10 Years 11-15 Years 16-20 Years 21-25 Years >25 Years
	0-5 Years 6-10 Years 11-15 Years 16-20 Years 21-25 Years >25 Years

Other Information

1. Please provide a list of high priority challenges facing your irrigation entity. These may include inadequate water sources, state and federal requirements, unwritten easements, maintenance through subdivisions, legal problems, subdivided land, water rights, assessments, etc.
      a)
      b)
      c)
      d)
      e)

2. Are you familiar with the grant/loan program for agricultural projects administered through the Wyoming Water Development Commission? Yes No

3. Would you like Program information sent to you? Yes No

Thank you for your participation!
Dept. 3943 | 1000 E. University Ave. | Laramie, WY 82071
Office: (307) 766-6651 email: wrds@uwyo.edu