Mailing Information:

1. Name of Entity:
   
2. Type of Entity:   Municipality District Joint Powers Board Private Company Other
      If Other, please list:
   
3. Contact Person: Email:    Website: 
             Address: Phone:
          City/Town:  State: Zip Code: County:
   
4. Water Division:   1 2 3 4
5. PWS ID:          
   

Water System Data:

1. Number of wells: Depth of wells (ft): Total production yield of wells (gpm):
   
2. Number of springs: Total production yield of springs (gpm):
   
3. Surface water source name(s):
   
4. Types of surface water diversion(s):
   
5. Total diversion amount: gpm, Or cfs
   
6. Other water sources:
   
7. Total system capacity (gallons/day):
   
8. Total raw water storage (gallons): Total treated water storage (gallons):
   
9. Treatment method(s):
   

Water System Usage:

1. Total population served: # of taps in entity: # of taps outside entity:
2. Total annual water use by the system (gallons):
3. Peak day water use for the system (gallons):     
4. Do you sell bulk water? Yes No    If yes, what is the cost/gallon:
5. What is the annual bulk water sales volume (gallons)?
6. Is the bulk water sold treated, untreated, or both? Treated Untreated Both
7. Do you sell water to other entities? Yes No    If yes, to whom:
8. Do you buy water from other entities? Yes No    If yes, from whom:
9. How much water do you buy? (gallons)?
10. What is the cost/gallon of the bulk water purchased?
11. What is the estimated loss to leakage? gpd, Or %

Billing Rates

1. What % of the system is metered? Does the entity bill by meter? Yes No
2. What are the unmetered uses within the system, if any?
   
3. What is the average residential monthly water bill?
   

4. 	Tap Fees ($)	Base Water Rate ($)	Gallons Included in Base Rate
   Residential
   Commercial
   Industrial
   Other

5. What is the rate for each 1000 gallons above the base amount?
   
6. What would a household's bill be for using 5,000 gallons in a month?  
   
7. What would a household's bill be for using 10,000 gallons in a month?
   
8. What would a household's bill be for using 20,000 gallons in a month?

Water System Fiscal Data

	$
What is the annual budget for the system?
How much is spent on operation and maintenance annually?
What does water quality testing cost annually?
What is annual payment/contribution to repair/replacement (sinking) fund?
What is the total balance in the repair/replacement (sinking) fund?
What is annual payment/contribution to the emergency fund?
What is the total balance in the emergency fund?
What are annual revenues from water bills?
What are annual revenues from tap fees?

1. Is the water system financially self-supporting? Yes No
2. Are there other funding sources for the water system? Yes No    If yes, what are they?

Wellhead Protection and Conservation Measures

1. Is there a wellhead protection plan in place? Yes No
2. What types of water conservation measures are in place?
   
3. What is the estimated water savings from the conservation measures? %
   

Comments?

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