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COLORADO DIVISION OF WATER RESOURCES DEPARTMENT OF NATURAL RESOURCES 1313 SHERMAN ST., RM 818, DENVER CO 80203
phone ­ info: (303) 866-3587 main: (303) 866-3581 Fax: (303) 866-3589 http://www.water.state.co.us

Office Use Only

Form GWS-72 (9/2004)

GEOEXCHANGE SYSTEM LOOP FIELDS Permit Application
Review instructions on reverse side prior to completing form. The form must be completed in black or blue ink or typed.

1. Applicant Information
Name of Applicant

Office Use Only

Mailing address

City

State

Zip code

Telephone #

(

)

2. Business Information (if applicable)
Name of business

Mailing address (Check box if same as above

)

City

State

Zip code

Telephone #

(

)

3. Certified Individual Certification No.
Certification No.

4. Type Of Geoexchange System To Be Constructed (check applicable boxes)
Horizontal Vertical (As defined in Rule 4.2.28.2) (As defined in Rule 4.2.28.3)

5. Refer To Permit No. Last Issued (if applicable)
Permit No.

6. Signature Of Applicant Or Authorized Agent
As an applicant for a well permit to construct loop fields for geoexchange systems, I attest that I shall adhere to the guidelines and be in compliance of the Geothermal Well Rules 2 CCR 402-10. I understand that a permit to construct loop fields for geoexchange systems does not ensure that no injury will occur to valid, prior water or geothermal rights, or preclude an owner of a valid, prior water or geothermal right from seeking relief in a civil court action. Furthermore, I agree that at a minimum I will use the Division of Water Resources Online Mapping tool to assist in identifying what valid, prior water or geothermal rights are located within ½ mile of the proposed loop fields. 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 have read the statements herein, know the contents thereof and state that they are true to my knowledge.

Receipt area only

Sign here (Must be original signature)

Date

Print name & title

COLORADO DIVISION OF WATER RESOURCES DEPARTMENT OF NATURAL RESOURCES

GWS-72 GEOINST (9/2004)

GEOEXCHANGE SYSTEM LOOP FIELDS PERMIT APPLICATION INSTRUCTIONS
Applications must be typewritten or printed, in BLACK or BLUE INK. ALL ITEMS in the application must be completed. Incomplete applications may be returned to the applicant for more information. Please allow up to forty-five (45) days for processing. This form may be reproduced by photocopying or computer generation. Reproductions must retain margins and print quality of the original form. FEES: This application must be submitted with a $480 filing fee. Acceptable forms of payment are check or money order, payable to the Colorado Division of Water Resources, and Visa or MasterCard (card number and expiration date must be provided on a separate sheet). Fees are nonrefundable. USE: This form (GWS-72) must be used when applying for a permit pursuant to the Geothermal Rules (2 CCR 402-10) to construct geoexchange system loop fields to utilize the earth's geothermal properties. A copy of the Rules may be obtained from any Division of Water Resources Office for a nominal fee, or you may refer to our web site at http://www.water.state.co.us. ITEM INSTRUCTIONS: (numbers correspond with those on the front of this form) 1. Provide the name of the applicant and the mailing address where correspondence can be sent. 2. Provide the name of the business and the mailing address where correspondence can be sent. If the business mailing address is the same as in Item 1, check the box provided in Item 2. 3. Provide the certification number assigned to the applicant by the Division of Water Resources. Please note that pursuant to Rule 6.2.1 of the Geothermal Rules, only a certified individual can apply for a permit under this application. Rule 4.2.4 of these same Rules defines a certified individual as "an individual who is certified by the State Engineer to perform/supervise the drilling or grouting in the construction of loop fields in vertical closed-loop geoexchange systems, or to perform/supervise the excavation and backfilling of loop fields in horizontal closed-loop geoexchange systems or submerge loop fields in a body of water." 4. Indicate what type of geoexchange system loop fields will be constructed under this permit by checking all applicable boxes. 5. If the applicant has been previously issued a permit to construct geoexchange system loop fields, the permit number of the last previously issued permit should be referenced in this Item. Pursuant to Rule 7.8 of the Geothermal Rules, a permit is issued for a period of one (1) year and cannot be extended. 6. The application must be signed and when submitted to the Division of Water Resources contain an ORIGINAL signature of the applicant or their authorized agent. An authorized agent is an individual who has been authorized in writing by the applicant to act in his/her behalf. A copy of such written authorization must be attached to the permit application. IF YOU HAVE ANY QUESTIONS regarding any item on the application form, please call the Division of Water Resources Ground Water Information Desk (303-866-3587), or the nearest Division of Water Resources Field Office located in Greeley (970-352-8712), Pueblo (719-542-3368), Alamosa (719-589-6683), Montrose (970-249-6622), Glenwood Springs (970-945-5665), Steamboat Springs (970-879-0272), or Durango (970-247-1845), or refer to our web site at http://www.water.state.co.us for general information, additional forms, and access to state rules or statutes.