Free Microsoft Word - Document3 - Colorado

Form No. GWS-11 1/2009

STATE OF COLORADO OFFICE OF THE STATE ENGINEER
818 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 Phone ­ Info: (303) 866-3587 Main: (303) 866-3581 Fax: (303) 866-3589 http://www.water.state.co.us

For Office Use Only

CHANGE IN OWNER NAME/ADDRESS
CORRECTION OF THE WELL LOCATION
Review instructions on the reverse side prior to completing the form. Name, address and phone of person claiming ownership of the well permit: NAME(S): Mailing Address: City, St. Zip: Phone: ( ) -

E-mail (optional): This form is filed by the named individual/entity claiming that they are the owner of the well permit as referenced below. This filing is made pursuant to C.R.S. 37-90-143. WELL LOCATION: Well Permit Number: County (Address) 1/4 of the 1/4, Sec. , Twp. Ft. From N. or N. or S., Range S., Lot Receipt Number: Well Name or # (optional) (City ) E. or W., E. or W. Line. Case Number:

(State)

(Zip) P.M.

Distance from Section Lines: Subdivision Name

Ft. From , Block

, Filing/Unit

The above listed owner(s) say(s) that he, she (they) own the well permit described herein. The existing record is being amended for the following reasons: Change in name of owner Change in mailing address Correction of location for exempt wells permitted prior to May 8, 1972 and non-exempt wells permitted before May 17, 1965. Please see the reverse side for further information regarding correction of the well location. I (we) claim and say that I (we) (are) the owner(s) of the well permit described above, know the contents of the statements made herein, and state that they are true to my (our) knowledge. Signature(s) of the new owner Please print the Signer's Name & Title Date

It is the responsibility of the new owner of this well permit to complete and sign this form. Signatures of agents are acceptable if an original letter of agency signed by the owner is attached to the form upon its receipt. For Office Use Only

_________________________________ State Engineer

_________________________________________ By

_______________ Date

Form No. GWS-11 1/2009

INSTRUCTIONS FOR CHANGE IN OWNER NAME/ADDRESS/LOCATION CORRECTION NO FEE IS REQUIRED The form must be typewritten or printed in BLACK OR BLUE INK. Initial and date any changes you make on the form. THIS FORM MAY BE REPRODUCED BY PHOTOCOPYING OR WORD PROCESSING MEANS. INCOMPLETE FORMS WILL BE RETURNED. Be sure to include the well permit number in the space provided in the section titled "WELL LOCATION". The form is to be completed by the well permit owner (the individual, company or entity claiming ownership of the well permit). Print the well permit owner's name and include the mailing address and phone number, and optional e-mail address. Complete the well location information. The Well Name or # is optional and is a designation provided by the well permit owner. If the address of the well location is different than the mailing address of the owner, include the address where the well is located. The actual well location must include ¼, ¼, Section, Township and Range. Check the appropriate boxes for North or South and East or West directions. Complete the Subdivision, Lot, Block and Filing information, if applicable. Indicate in the appropriate boxes if the form is submitted to change the ownership and/or address, or both. The individual, company or entity claiming ownership of the well permit must sign the form. Sign the first block and date the last block. If you are signing as a representative of a company who owns the well permit, then your title must also be included in the second block. If you want confirmation of this processed form mailed to you, please attach a note requesting this when submitting the form. USE THIS FORM TO CORRECT THE LOCATION OF A WELL IF: A. The well was permitted, registered, or first used 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. B. The well is not of the type described in A above, but was permitted or registered prior to May 17, 1965. Inside the Designated Ground Water Basins, other procedures and publication may be required. IN ALL OTHER CASES USE FORM GWS-42 (CORRECTION OF WELL LOCATION FORM). If you have questions, contact the Denver Office or the Division Office where the well is located. Contact information is also available from our website at http://www.water.state.co.us.