Free Microsoft Word - Document1 - Colorado

Form No. GWS-42 8/2008

STATE OF COLORADO OFFICE OF THE STATE ENGINEER 1313 Sherman St. Rm. 818 Denver CO 80203 Phone - info: (303) 866-3587 Main: (303) 866-3581 Fax: (303) 866-2223 http://www.water.state.co.us

For Office Use Only

APPLICATION FOR WELL LOCATION AMENDMENT
PRIOR TO COMPLETING THIS FORM, SEE INSTRUCTIONS ON REVERSE SIDE

WELL OWNER: Name(s) Mailing Address City: Phone: WELL LOCATION: Well Permit Number: County (Address at well location) 1/4 of the 1/4, Sec. , Township Ft. N. or S. Line, N. or State: Zip Code: WE CONT. MNGR. Div WD Basin MD

Receipt Number: Owner's Well Designation (optional) (City ) S., Range Ft. E. or E. or , Lot W., (State) (Zip) P.M.

Distance from Section Lines Subdivision Name

W. Line. , Block , Filing/Unit

Optional: GPS well location information in UTM format. The following GPS settings are required: Format must be UTM. Units must be in meters. Datum must be NAD83. Unit must be set to true north. Zone 12 or Zone 13. Was GPS unit checked for above items? YES NO

Easting Northing

The location of the existing well needs to be amended for the following reason(s): Attach appropriate documentation as necessary.

The making of false statements herein constitutes perjury in the second degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S. 24-4-104(13)(a). I (we) claim and say that I (we) (are) the owner(s) of the well described above, have read the statements herein, know the contents thereof, and state that they are true to my (our) knowledge. Signature(s) of the well owner or agent Please print the Signer's Name & Title Date

For Office Use Only

State Engineer

By

Date

Form No. GWS-42 8/2008

INSTRUCTIONS FOR APPLICATION FOR WELL LOCATION AMENDMENT FORM
The report must be typed or printed in BLACK OR BLUE INK. All changes on the form must be initialed and dated. Attach additional sheets if more space is required. Each additional sheet must be identified at the top by the well owner's name, the permit number, form name/number and a sequential page number. Incomplete forms will be returned for completion. This form may be reproduced by photocopy methods, or by computer.

DO NOT USE THIS FORM TO AMEND THE PERMITTED WELL LOCATION IF:
A. Your well was permitted, registered, or first used for any of the following purposes prior to May 8, 1972 for ordinary household purposes in up to three single-family dwellings, fire protection, the watering of poultry, domestic animals, and livestock on farms and ranches, and the irrigation of not over one acre of home gardens and lawns. (USE FORM GWS-11) Your well is not of the type described in A above, but was permitted or registered prior to May 17, 1965. USE FORM GWS-11. Inside the Designated Ground Water Basins, other procedures and publication may be required. Your well was decreed by the Water Court for the correct location, DO NOT USE THIS FORM TO AMEND THE PERMITTED WELL LOCATION. YOU MAY USE FORM GWS-11.

B.

C.

USE THIS FORM IF:
D. Your well was permitted or first used on or after May 8, 1972, and was approved under the provisions of C.R.S. 37-92-602 and C.R.S. 37-90-105. (This number will appear in the permit conditions of approval and permit numbers generally are not followed by a suffix. If the well has been replaced, the number is followed by the suffix "A" such as 75550, 75600-A, or 165000.) A $60 filing fee is required to accompany a request to amend the location of this type of well. Your well is not one of the types described in A, B, C, or D above. A filing fee of $100 is required to accompany a request to amend the well location. Inside Designated Ground Water Basins, publication may be required.

E.

GENERAL INSTRUCTIONS
Print the Owner's Name and indicate the mailing address and phone number. Print the well permit number in the space provided under the section titled "Well Information". Complete the CORRECT well location information of where the well was drilled. If the owner has more than one well serving this property, provide the identification (Owner's Well Designation) for this well. The well location must include the ¼, ¼, Section, Township, Range, Principal Meridian, and distances from section lines. For wells located in subdivisions the lot, block, and subdivision information must also be provided. An option to providing distances from section lines is to provide an accurate GPS location in UTM format. The required GPS unit settings must be as indicated on this form. Colorado contains two (2) UTM zones. Zone 13 covers most of th th Colorado. The boundary between Zone 12 and Zone 13 is the 108 Meridian (longitude). West of the 108 th th Meridian is UTM Zone 12 and east of the 108 Meridian is UTM Zone 13. The 108 Meridian is approximately 57 miles east of the Colorado-Utah state line. On most GPS units, the UTM zone is given as part of the Easting measurement, e.g. 12T0123456. Check the appropriate box. Indicate the reason(s) the location must be corrected. If this well was approved on as the only well on the tract of land of 35 acres or more (see well permit conditions of approval) and approved prior to July 1, 1984, please verify that this is correct and include the metes and bounds description or survey plat of the tract. The owner of the well must sign this application. Sign your name in the first block. Print or type your name and title in the second block. Print or type the date in the third block. If you are signing as a representative of a company who owns the well, then your name must also be included in the second block.





Approval of this request will also update the well owner and mailing address. In some cases, this request to correct the location may not be accepted.

If you have questions, contact the Denver or the Division Office where your well is located. Contact information is also available from our website at http://www.water.state.co.us.