Producer .......

Code .............

Person Reporting:

First Name ....

Last Name.....

Quarter of Water Year Reporting:-- ? Oct-Dec 2008 Jan-Mar 2009 Apr-Jun 2009 Jul-Sept 2009

Well # 1- Amount Pumped: Units Reporting: ? Gallons Cubic Feet Acre Feet

Well # 2- Amount Pumped: Units Reporting: ? Gallons Cubic Feet Acre Feet

Well # 3- Amount Pumped: Units Reporting: ? Gallons Cubic Feet Acre Feet

Well # 4 -Amount Pumped: Units Reporting: ? Gallons Cubic Feet Acre Feet

Well # 5- Amount Pumped: Units Reporting: ? Gallons Cubic Feet Acre Feet