Free GWS-68, EXISTING WELL INFORMATION AND INSPECTION FORM - Colorado

Form No. GWS-68 2/2005

EXISTING WELL INFORMATION AND INSPECTION FORM
Division of Water Resources, 1313 Sherman St., Rm 818, Denver, CO 80203 PLEASE COMPLETE THIS FORM IN BLACK INK

PERMIT NO: _________________ RECEIPT NO: ____________________ DIV: ____ WD: ____ Existing Well Location: _____ ¼ of the _____ ¼, Sec. _____, Twp _____, Rng _____, _____ P.M. _______ feet from N/S sec. line, _______ feet from the E/W sec. line; County _________________ Existing well owner: Name: __________________________________________ Mailing Address: _____________________________________________________ City/State/Zip___________________________________Telephone: (_____)______________________ Description of parcel (subdivision, lot, blk, flg) _________________________________ Size _____ ac Existing well location and visual conditions: If stating no, please explain Type of Existing Well: Drilled, Hand Dug, Spring Well, Gallery Well, Gravel Pit, Other _______________ Distance to nearest septic tank/sewer line (approximate) _________________ feet Distance to nearest leach field (approximate) ___________________ feet Is the well in a clean and sanitary location? _____________ Is the well maintained in a clean and sanitary condition? _____________ Is the ground at the surface sloped away from the well for proper drainage? __________ Is the surface surrounding the well firm and stable? ____________ Is the well situated in a well house or vault? _________ If so, is the well house or vault in good repair and condition? ______________ Existing well construction and materials: If stating no, please explain Is the well equipped with a sanitary well seal/cap? _____________ Is the well constructed with steel casing at the surface? ____________ Does the casing extend at least one (1) foot above the surface? __________ Casing size ________ in; Estimated well depth ___________ feet Who constructed well? ___________________________; Who installed pump?___________________ Current uses of existing well: Were the existing uses initiated prior to May 8, 1972? _________ _____Household use in _____ single-family dwellings _____Watering of poultry and/or domestic animals _____Watering of livestock on farm or ranch; approximately how many head? _____ Is this a feedlot? _____; How many head? _____ _____Lawn and/or garden __________ square feet _____Crop Irrigation _________ acres _____Fire Protection _____Commercial exempt for ______________________________________ _____Other: _______________________________________________ Estimated date well constructed ________________; Estimated date pump installed ________________ Estimated date of first use _______________________; Estimated flow rate _____________ gpm How many other wells are located on this parcel? _____; Uses: _____________________________; Permit/Case Nos.: ___________________________________________________________________ Existing Well Owner Signature: ____________________________ Date: _____________________ ------------------------------------------------------------------------------------------------------------------------------------------For Office Use Only Has information above been verified? _________ If not, please note accordingly. List any problems you have identified: (if none, please state so)_________________________________ ___________________________________________________________________________________

Date of inspection: ___________________ Phone Number ___________________________ Inspected by (print): ________________________________ (signed): ___________________________________
Attach photo(s) if available or needed for further evaluation. Additional comments or information on back.