Free April 2, 1999 - Colorado

Form No. GWS-71 9/03

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

For Office Use Only Div _______ WD ________ Basin ______ MD ______

NON-EXEMPT WELL SUPPLEMENTAL INFORMATION
(To be submitted with Form GWS-45) Name, address and phone of the well owner: NAME(S) ____________________________________________________ Mailing Address _______________________________________________ City, St. Zip ___________________________________________________ Phone ( ) __________________________ AUGMENTATION OR SUBSTITUTE SUPPLY PLAN INFORMATION Name of Plan:
Water Court Case No:

WELL INFORMATION Permit No: Water Court Case No: Date Constructed: WELL LOCATION(S) Decreed Well Location _____1/4 of the_____ 1/4, Sec. ____, Twp. _______ _________ Ft from the N or S Section Line; Existing Well Location Same as decreed _____1/4 of the_____ 1/4, Sec. ____, Twp. _______ _________ Ft from the N or S Section Line;

Contract No: Attach additional information

Number of Units:

N. or

S., Range ______ E or

E. or

W., ____ P.M.

_________ Ft from the

W Section Line.

N. or

S., Range ______ E or

E. or

W., ____ P.M.

_________ Ft from the

W Section Line.

Proposed Well Location Same as decreed Same as Existing _____1/4 of the_____ 1/4, Sec. ____, Twp. _______ _________ Ft from the N or S Section Line;

N. or

S., Range ______ E or

E. or

W., ____ P.M.

_________ Ft from the

W Section Line.

600 Foot Spacing Are there wells, not owned by the applicant, that are within 600 feet of the proposed well location? Yes No If yes, please attach additional information including owner contact information, well permit nos. and approximate location. Use Of Well (check applicable boxes)
Attach a detailed description of uses applied for. Industrial Municipal Irrigation Commercial I (we) claim and say that I (we) 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. Other (describe):

Land On Which Well Will Be Used (If For Irrigation)
Number of Acres Legal Description: (may be provided as attachment)

Please print the Signer's Name & Title ____________________________________ ____________________________________

Signature(s) of the owner. _____________________________________ _____________________________________

Date ____________________