Free Microsoft Word - Document1 - Colorado

Form No. GWS-10 02/2005

STATE OF COLORADO GROUND WATER COMMISSION DIVISION OF WATER RESOURCES 818 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 (303) 866-3581 Fax (303) 866-3589 www.water.state.co.us
(For wells located within a Designed Ground Water Basin.)

For Office Use Only

STATEMENT OF BENEFICIAL USE
1. Insert the Well Permit Number: 2. Name, address and phone number of the well owner: NAME(S): Mailing Address: City, State, Zip: Phone: ( )
____________________________________
(Review the instructions for completing this Statement on the reverse of the form.)

3. WELL LOCATION: County 1/4 of the 1/4, Section , Township feet from North or North or South,

Owner's Well Designation South, Range West of the Sixth P.M. feet from East or West, section lines.

Distance from Section Lines:

4. The well is being used for the following purpose(s):

5. Water from the well was first beneficially used, under this permit for the above-described purpose(s), on the following date: 6. The pumping rate claimed is gallons per minute. acre-feet.

.

7. The maximum annual amount of water diverted by the well for the above-described purpose(s) is 8. The land irrigated by water from this well is
number

acres, described as:

9. Well constructed by: Pump installed by: 10. Meter Mfg. by: Serial No.

License No. License No. Date Installed

I (we) claim and say that I (we) am (are) the owner(s) of the well described above, know the contents of the statements made herein, and state that they are true to my (our) knowledge.
Please print the signer's name & title: Signature(s) of the well owner(s): Date:

For Office Use Only

_________________________
State Engineer

_____________________________________
By

______________________
Date

INSTRUCTIONS FOR COMPLETION OF STATEMENT OF BENEFICIAL USE
IMPORTANT INFORMATION: For well permits approved pursuant to CRS 37-90-107, a statement of beneficial use must be received within three years from the date the permit was issued, as required in CRS 37-90-108(2)(a). Pursuant to CRS 37-90-108(4), a statement of beneficial use must be filed for all permits issued for large-capacity wells located within a designated ground water basin wherein water was first put to beneficial use since May 17, 1965. This Statement may also be used to describe the extent of beneficial use for wells put to use prior to May 17, 1965. Additional signed and dated declarations by previous well owners, verifying the extent of beneficial use of ground water claimed in a statement of beneficial use, may be attached to and made a part of the Statement. In accordance with CRS 37-90-108(2)(b), the Commission reserves the right to inquire and request verification concerning the amounts claimed on this form. These amounts are also subject to objection by others claiming to be injured. If the permit was approved pursuant to CRS 37-90-107(7), a statement of beneficial use is not required, however, form GWS-19 "Notice of Commencement of Beneficial Use" must be filed upon first beneficial use of the well. The Statement of Beneficial Use, form GWS-10, must be typewritten or printed in BLACK INK. Initial and date any changes you make on the form. Incomplete forms are not acceptable and will be returned. Attach additional sheets if more space is needed. The amounts and extent of beneficial use claimed in the Statement for permitted wells, must have occurred within three years of the date of permit issuance; for registered wells put to use prior to May 17, 1965, the amounts and extent of beneficial use claimed must have occurred prior to the filing date of the well registration. No fee is required to submit a statement of beneficial use, except a $30 fee may be required for late statements submitted for permits issued on or after July 14, 1975, as provided in CRS 37-90-108(4). 1. 2. 3. The well permit number must be indicated in the space provided at the top of the form. Print the well owner's name and include the mailing address and phone number. The actual well location must include 1/4, 1/4, Section, Township and Range, and the measured distances from Section lines. Mark the appropriate boxes for the north or south Section line and the east or west Section line. If the owner has more than one well, the well name or number as designated by the owner may be indicated in the space provided. Describe the use(s) to which the water has actually been applied. Enter the date of first beneficial use. This is the date water from the well was first used beneficially for the purposes described in this Statement. The date claimed cannot predate the issuance of the permit; it is not the date the form is completed, nor is it the date the well was test pumped. However, if the Statement is used to describe extent of use for a registered well used prior to May 17, 1965, date of first beneficial use may predate the filing date of the registration. Enter the pumping rate claimed. The rate cannot exceed the permitted maximum rate or the actual tested sustained pumping rate in gallons per minute, whichever is less. Enter the annual amount of water diverted, for the claimed beneficial uses, in acre-feet. The amount claimed cannot exceed the actual amount applied to beneficial use in a calendar year or the permitted amount as limited by any conditions of approval, whichever is less. For wells used only for irrigation and not having a permitted or registered annual amount to be diverted, the Commission guideline of 2-1/2 acre-feet per irrigated acre (except for in the Southern High Plains Basin where this guideline is 3-1/2 acre-feet per irrigated acre) may be claimed. Report the area irrigated by filling in the correct number of acres irrigated. Describe the specific area irrigated by indicating the legal description of the irrigated area and/or providing a scale map of the area as an attachment to the Statement. If the well is not used for any type of irrigation, place a zero in the acres irrigated space. Indicate the well construction and pump installation contractors and their license numbers. If you did the work yourself, report this by indicating "owner" or "self" in the license number area, and submit the required well completion and/or pump installation report.

4. 5.

6. 7.

8.

9.

10. If a totalizing flow meter is required as a condition of the permit, indicate the meter manufacturer name, it's serial number and the date of installation. The well owner must sign the Statement. Print or type the well owner name in the first block. If signing as a representative of a company or corporation owning the well, your name and title must be indicated in the first block. Sign the second block and date the last block.

If you have questions, contact the Ground Water Commission Staff at the Division of Water Resources, 1313 Sherman St, Room 818, Denver, CO 80203, or call the "ground water information desk" at 303-866-3587.