Harris-Galveston Subsidence District
Serving the Gulf Coast Community Since 1975

Affidavit of Meter Calibration Test
Instructions:
Items marked with an * are required.

*Permittee Name:  
*Well No.:  
*Description of site at location:  
*Meter Manufacturer:  
*Serial No.:  
*Type:  
*Testing Firm:  
*Mailing Address:  
*City:      *State:       *Zip:  
*Phone Number:  (###-###-####)       Ext.:  
*Test Supervisor:  
*Title:  
*Details of Test: 
*Date of Test:  (mm/dd/yyyy)    
*Description of Test:  
*Unit Serial No.:  
Please fax or mail a diagram of installation tested, including the test equipment used.  A schematic diagram is acceptable if pipe dimensions are given.  Include a copy of test tape if transit time method is used.
Test Results:
*Meter reading at start of test:  Gallons  
*Meter reading at end of test:  Gallons  
*Metered quantity (item 2 - item 1):  Gallons  
*Known standard quantity in test:  Gallons 
*Percent accuracy (item 3 รท item 4 x 100)  %  
*Flow Rate:  Gallons/Min  
*Pipe Diameter:  in.  
*Recalibration:  
Percent Accuracy after Recalibration:  %
Remarks:
*Applicant/Agent Name:  
*Please enter your e-mail address:   
*Please re-enter your e-mail address:  
   

1660 W. Bay Area Boulevard  •  Friendswood, TX 77546-2640
Phone: (281) 486-1105  •  Fax: (281) 218-3700
www.subsidence.org