Free Adobe Acrobat (pdf) Format - Colorado

Form No. GWS-12 7/2009

STATE OF COLORADO OFFICE OF THE STATE ENGINEER
1313 Sherman St., Room 818, Denver, CO 80203 Phone ­ Info: (303) 866-358 Main: (303) 866-3581
Fax (303) 866-3589 http://water.state.co.us/default.htm

For Office Use Only

REGISTRATION OF EXISTING WELL
Review form instructions prior to completing form NAME & CONTACT INFORMATION OF WELL OWNER: NAME(S) MAILING ADDRESS CITY: TELEPHONE NUMBER ( ) WELL LOCATION County (Address) 1/4 of the 1/4, Sec. , Twp. Ft. N. or N. or S. Line, S., Range Ft.

STATE:

ZIP CODE:

E-MAIL (OPTIONAL)
Owner's Well Designation (optional) (City ) E. or E. or W., (State) P.M. (Zip)

Distance from Section Lines

W. Line.

ATTACH A COPY OF A CURRENT DEED FOR THE SUBJECT PARCEL
Subdivision Name ____________ _____ , Lot , Block Easting Northing , Filing/Unit Optional: GPS well location information in UTM format. The following GPS settings are required: Format must be UTM. Units must be in meters. Datum must be NAD83. Unit must be set to true north. Zone 12 or Zone 13 Was GPS unit checked for above items? YES NO The well has historically been used for the following purpose(s):

Water from the well was first used beneficially by the original owner for the above described purposes on The total depth of this well is The pumping rate of this well is The average annual amount of water diverted is The lawn and garden irrigated (watered) by water from this well is Number The making of false statements herein constitutes perjury in the second degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S. 23-3-104(13)(a). I have read the statements herein, know the contents thereof, and state that they are true to my knowledge. Signature(s) of the Well Owner(s) Print Name and Title of Well Owner(s) Date feet. gallons per minute. acre-feet. Acre or Square feet.

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For Office Use Only WE WR CWCB AQUA MYLAR Div WD Basin MD

REGISTRATION OF EXISTING WELL APPLICATION INSTRUCTIONS

GWS-12 (7/2009)

The Form must be completed in BLACK OR BLUE INK or typed. 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.
Certain wells not previously registered or permitted may be registered pursuant to C.R.S. 37-92-602(5) or 37-90-105(4). The wells must have been constructed and put to beneficial use prior to May 8, 1972. The types of wells that may be registered are identified as follows: 1) 2) 3) 4) 5) Wells not exceeding fifteen gpm which are used for ordinary household purposes, fire protection, the watering of poultry, domestic animals and livestock on farms and ranches, the irrigation of not over one acre of home gardens and lawns, but not used for more than three single family dwellings. Wells not exceeding fifty gpm which were in production as of May 22, 1971, and were and are currently used for purposes not exceeding those described in (1) above. Wells not exceeding fifteen gpm, which are used for drinking and sanitary facilities in individual commercial businesses. Wells used exclusively for fire-fighting purposes if the wells are capped, locked and are used only in fighting fires. Wells within Designated Groundwater Basins may be registered provided they do not exceed 50 gpm and are used for not more than three single family dwellings and the irrigation of not over one acre of home gardens and lawns, the watering of livestock on range and pasture, or use in one commercial business.

If uncertain as to whether or not the existing well was previously registered or permitted and you need assistance from this office, you may complete and submit the online "Find My Well Permit Request Form " on the CDWR website at http://www.water.state.co.us.

FEES: The filing fee for this Form No. GWS-12 application is $100. If this is application and an application for a permit to replace the old existing well in the same aquifer (Form Nos. GWS-44 or 45) are submitted together, the combined filing fee is also $100. Fees are nonrefundable. Acceptable forms of payment are check or money order, payable to the Colorado Division of Water Resources, and Visa, MasterCard or Discover (card number and expiration date must be provided on a separate attachment). INSTRUCTIONS:
Print the well owner's name and include the mailing address and phone number. If 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 designation, section #, township, range, principal meridian, and distances from section lines. Mark the appropriate boxes for North or South and East or West directions. (An option to providing distances from section lines is to provide a GPS location (UTM coordinates). The required GPS settings must be as indicated on the front of this form. If providing a GPS location, the ¼, ¼ section designation, section number, township, range, and principal meridian must still be provided.) Colorado contains two UTM zones (12 & 13). Zone 13 covers most of th th Colorado. The boundary between Zone 12 and Zone 13 is the 108 Meridian (longitude). West of the 108 Meridian is UTM Zone 12 and th th east of the 108 Meridian is UTM Zone 13. The 108 Meridian is approximately 57 miles east of the Colorado-Utah state line. On most GPS units, the UTM zone is given as part of the Easting measurement, e.g. 12T0123456. Check the appropriate box for the zone. Attach a current deed for the subject parcel. Describe the use(s) to which the water has actually been applied. If you are also applying to install a rooftop precipitation collection system, complete Form No. GWS-78 and submit it with this application. No additional filing fee is required. Enter the date of first beneficial use by the original owner. This date must be prior to May 8, 1972. Any expanded use of the well that occurred on or after May 8, 1972, or any use that has been abandoned by 10 or more consecutive years of non-use, cannot be included in this application and does not qualify for registration. Enter the total depth of the well. Enter the pumping rate of the well in gallons per minute. The annual amount of water diverted in acre-feet must be indicated. One acre-foot is equivalent to 325,851 gallons. A typical home with approximately 13,000 square feet of lawn and garden irrigation and a few head of cattle diverts an average of one acre-foot. Average home use that does not include lawn and garden irrigation or animal watering diverts 1/3 acre-foot. Report the area of lawn and/or garden irrigation either as one acre, fraction of one acre or square feet by filling in the correct number and check the appropriate box. If the well is not used for irrigation, place a zero in the acres irrigated blank. One acre is equivalent to 43,560 square feet. The well owner must sign the form in the first block. Print or type your name in the second block if it is different from that stated in the Name block on the front of the application at the top. If signing as a representative of a company who owns the well, then your title must also be included in the first block. Put the date the application was signed in the last block. If your well location is inside of Water Divisions 1 (South Platte River Basin) or 2 (Arkansas River Basin) you must also complete Form No. GWS-12-A, Statement of Historical Use, and submit it with this Form No. GWS-12. If your well location is inside Water Divisions 3 (Rio Grande River Basin), 4 (Gunnison River Basin), 5 (Colorado River Basin), 6 (Yampa/White River Basins) or 7 (San Juan/Dolores River Basins), the existence and use of the well must be verified by field inspection prior to submitting this form. To request an inspection, contact the appropriate Division office (see contact information below). Please note that Water Divisions 3 ­ 7 may also require the completion of the supporting Form No. GWS-12-A.

QUESTIONS?: If you have any questions regarding any item on the application form, please call the Colorado Division of Water Resources
Ground Water Information Desk (303-866-3587), or the nearest Division of Water Resources Field Office located in Greeley/Div.1 (970-352-8712), Pueblo/Div.2 (719-542-3368), Alamosa/Div.3 (719-589-6683), Montrose/Div.4 (970-249-6622), Glenwood Springs/Div.5 (970-945-5665), Steamboat Springs/Div.6 (970-879-0272), or Durango/Div.7 (970-247-1845), or refer to the CDWR web site at http://www.water.state.co.us for general information, additional forms, and access to state rules or statutes.