Free GWS-12A, STATEMENT OF HISTORICAL USE - Colorado

INSTRUCTIONS FOR THE COMPLETION OF STATEMENT OF HISTORICAL USE 7/2009 Certain wells not previously registered or permitted may be registered pursuant to § 37-92-602(5), C.R.S. (or § 37-90-105(4), C.R.S. in a Designated Ground Water Basin). 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) Wells not exceeding fifteen (15) gpm which are used for ordinary household purposes, 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, but not used for more than three single family dwellings. Wells not exceeding fifty (50) gpm which were in production as of May 22, 1971, and were and are currently used for the purposes described in (1) above. Wells not exceeding fifteen (15) 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; use in one commercial business. They may be further restricted by applicable Ground Water Management District Rules and Regulations.

2) 3) 4) 5)

The Form must be typewritten or printed in BLACK or BLUE INK. Initial and date any changes you make on the form. Incomplete forms are not acceptable and will be returned. This form is to be submitted with the Registration of Existing Well form (GWS-12) The Well Owner is to complete this form. Attach additional sheets if more space is needed to explain an answer. The well location must match the location indicated on the Registration of Existing Well form (GWS-12) Describe the existing well location, condition, and construction to the best of your knowledge. Enter the historical use of this well. The area of home lawn and/or garden irrigation (not to include crop or pasture irrigation) may be indicated in square feet or as a fraction of an acre (up to a maximum one (1) acre). One acre is equivalent to 43,560 square feet. The claimed historical use must have been initiated prior to May 8, 1972. The location of the historical use must be identified with street address and/or subdivision name/lot/block/filing as applicable. If the future place of use is different than the historical place of use, you must also identify the proposed future place of use. Uses not initiated prior to May 8, 1972, or any expansion of use that occurred after May 8, 1972 are not eligible for registration. If the claimed uses have not been in continuous use since May 8, 1972, you must identify the dates when the well was used for the claimed uses. Uses that have not occurred for ten (10) or more continuous years are considered abandoned and cannot be registered. Only the uses identified in the beginning of the instructions above are potentially eligible for registration. Other uses such as crop irrigation, filling a pond, industrial, municipal, etc., are not eligible for registration. If you are applying for a permit to use an existing well that was not used prior to May 8, 1972, use either the Residential (GWS-44) or General Purpose form (GWS-45), as applicable, and complete the existing well inspection form (GWS-68). The owner of the well must sign the form. If signing as a representative of a company who owns the well, you must also indicate your title. It is the responsibility of the well owner completing this form to have knowledge of the historical use of this well. If you do not have knowledge of the use of this well since May 8, 1972, it is your responsibility to research and determine the historical use of the well to support the historical use claims made herein.

If you have questions, contact the Denver or the Division Office where your well is located. Water Divisions and offices are based on major river drainage areas. For example, the Division One Office administers the South Platte River Basin. Division 1 th nd 810 9 St. 2 Floor Greeley, CO 80631 (970) 352-8712 Fax (970) 391-1816 Division 5 Direct mail to Box 396 Glenwood Spgs CO 81602 50633 U.S. Hwy 6 & 24 Glenwood Spgs., CO 81601 (970) 945-5665 Fax (970) 945-8741 Call First Division 2 310 E. Abriendo Ave Ste B Pueblo, CO 81004 (719) 542-3368 Fax (719) 544-0800 Division 6 Direct mail to Box 773450 505 Anglers Dr. Suite 101 Steamboat Spgs, CO 80477 (970) 879-0272 Fax (970) 879-1070 Division 3 th 422 4 St Alamosa, CO 81101 (719) 589-6683 Fax (719) 589-6685 Division 7 160 Rockpoint Drive, Ste E Durango, CO 81301 (970) 247-1845 Fax (303) 866-5417 Division 4 1871 East Main St. Montrose, CO 81402 (970) 249-6622 Fax (970) 249-8728 Denver Office 1313 Sherman St. Rm. 818 Denver, CO 80203 (303) 866-3581 Fax (303) 866-3589

Form No. GWS12-A 7/2009

COLORADO DIVISION OF WATER RESOURCES DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., RM 818, 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

STATEMENT OF HISTORICAL USE
Review form instructions prior to completing form This form is to be submitted with the Registration form, GWS-12

I,

___________________________________________ do state as follows: I am the owner of a well located in the
(print name of well owner)

_______1/4 of the_______ 1/4, Sec. _______, Township _______

N. or

S., Range _______

E. or

W , ______ P.M.

Water Court case no. ____________________(if applicable), Owner's well designation (well name)______________________________ Location of well (street address - if applicable): ________________________________________________________________________ Location of well (subdivision name/lot/block/filing ­ if applicable): __________________________________________________________ _____________________________________________________________________________________________________________ Is historical use on same parcel as where well is located? ____ Yes/ ____ No. If no, provide location where well is used (address/subdivision name/lot/block/filing): ___________________________________________________________________________ Size of parcel where well is located_______ acres. Will this be the only well on the parcel? ____ Yes/ ____ No. If no, list permit number(s) or water court decree case number(s) for other well(s)___________________________________________________________________ Will future use be on same parcel as historical? ____ Yes/ ____ No. If no, provide new location (address/subdivision name /lot/block/filing) ______________________________________________________________________________________________________________ Existing well location and visual conditions: If stating no, must include an explanation of the circumstances. Type of existing well (circle one): drilled; hand dug; spring well; gallery well; gravel pit; other _____________________________________ Distance to nearest septic tank/sewer line (approximate) ___________ feet. Distance to nearest leach field (approx.) ____________ feet. Is the well in a clean and sanitary location? ___________________________________________________________________________ Is the ground at the surface surrounding the well firm and stable and sloped away from the well for proper drainage? _________________ 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, must include an explanation of the circumstances. Is the well equipped with a sanitary well seal/cap? ____________________________________________________________________ Is the well constructed with steel casing that extends at least one (1) foot above the ground surface?_____________________________ Casing size (diameter) __________inches. Who constructed well? __________________________________ Who installed pump? _______________________________________ Historical use initiated prior to May 8, 1972 The well identified above has been used since prior to May 8, 1972 as the water supply for the following exempt uses listed in § 37-92-602, C.R.S. (or § 37-90-105, C.R.S., in a Designated Ground Water Basin): a) Ordinary household use inside _______ single-family dwelling(s) (maximum of 3 single family dwellings); b) The irrigation of _____________________ acre/square feet (circle one) of home gardens and lawns (maximum of one acre - one acre is equivalent to 43,560 square feet); c) The watering of domestic animals/poultry _____ yes/_____no; livestock on a farm or ranch _____ yes/ _____no OR (above uses cannot be combined with commercial uses) d) Drinking and sanitary facilities inside an individual commercial business ____ yes/ ____no (If commercial use claimed, Form GWS-57, Commercial drinking and sanitary well worksheet, must also be completed and submitted.) (Note: Commercial wells in a Designated Ground Water Basin may also include outside uses.) Have the above claimed uses been in continuous use since May 8, 1972? ____Yes/ ____No. If no, for each claimed use, list dates when this well supplied the above claimed uses: __________________________________________________________________________ I understand that uses that were not initiated prior to May 8, 1972 are not eligible for registration and any expansion of use that occurred after May 8, 1972 is not eligible for registration. Additionally, I understand that if the well has not been operational or has not existed for a period of at least ten (10) years, the well is not eligible for registration. The making of false statements herein constitutes perjury in the second degree, which is punishable as a class 1 misdemeanor pursuant to § 23-3-104(13)(a), C.R.S. I have read the statements herein, know the contents thereof, and state they are true to my knowledge.

Print Name & Title (Well Owner(s)) ____________________________________ ____________________________________

Signature of Well Owner(s) _____________________________________ _____________________________________

Date ____________________ ____________________