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GWS-13A (01/2007)

COLORADO DIVISION OF WATER RESOURCES FIELD INSPECTION REPORT
Please complete this form in ink DIV WD DATE OF INSPECTION: WATER COMMISSIONER NAME: PHONE NUMBER: ( ) APPLICANT: ADDRESS: PHONE: ( ) ext. Application Receipt No(s): WELL STRUCTURE NO. (IF APPLICABLE): PURPOSE OF INSPECTION: LATE REG OTHER or ( ) Person contacted if not applicant:

EXISTING WELL LOCATION: ¼, of the ¼, of Section , Township N or S, Range E or W, Distance from section line N or S, E or W, County OPTIONAL INFORMATION (GPS unit must be set for NAD83, meters, and true north) Zone 12 or 13 Easting Northing Mark type of existing well: drilled, hand dug, spring well, gallery well, gravel pit, other Estimated date well constructed: Date of first use: Estimate pumping rate: Total number of acres in this tract/parcel: acres Address of property (if different from than the applicant address): Additional subdivision /parcel information: Number of non-exempt acres irrigated: Name of Aug. Plan? Any other wells located on this property? (yes) how many , (no); permit #, case #, use? Use of Well:

P.M.

GPM

Household use in (indicate how many) single family dwelling(s) Watering of poultry, domestic animals, and livestock ­ approximately how many head? Watering of livestock only ­ approximately how many head? Is this a feed lot? yes no Estimated area of historical lawn and garden: Square feet acre of lawn and garden Fire protection Commercial ­ drinking & sanitary only? (write details in "comments" section) Other (write details in "comments" section) YES NO WERE THE USES CHECKED ABOVE INITIATED PRIOR TO MAY 8, 1972? NOTE: If ANY CHANGE IN HISTORIC USE OF THE WELL HAS OCCURRED SINCE MAY 8, 1972, please indicate the date(s) the use changed, and discuss this change/expansion of the current or proposed use in the comments section of this form. Signature of Water Commissioner: (NOTE: If filing electronically without a signature, please check the box. Additional comments and/or information: ) Dated:

More room for comments on the back Page 2, FIELD INSPECTION REPORT

GWS-13A (01/2007)