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GWS-3B (Rev. Sept. 1996)

STATE OF COLORADO OFFICE OF THE STATE ENGINEER DIVISION OF WATER RESOURCES NONTRIBUTARY GROUND WATER CONSENT LANDOWNERSHIP STATEMENT

I (We)_________________________________________________________________ (Name) whose mailing address is __________________________________________________ Street ______________________________________________________________________ (City) (State) (Zip) claim and say that I (we) am (are) the owner(s) of the following described property consisting of _________acres in the County of _______________________________, State of Colorado: (Insert Property Legal Description)

and that I (we) have granted written consent to others to withdraw ground water from the _____________________________ aquifer as evidenced by the attached copy of a deed or other document in the County or Counties in which the land is located, and that said ground water has not been conveyed or reserved to another, nor has consent been given for withdrawal by another except as indicated in the attached deed or other recorded document. Further, I (we) claim and say that I (we) have read the statements made herein; know the contents hereof; and that the same are true to my (our) own knowledge.

__________________________________________________ (Signature)

______________ (Date)

___________________________________________________ _____________ (Signature) (Date) ............................................................................................................................................ INSTRUCTIONS: Please type or print neatly in black ink. This form may be reproduced by photocopy or word processing means. See additional instructions on back. 1313 SHERMAN ST RM 818 DENVER CO 80203 (303)866-3581

9/26/96 NON-TRIBUTARY CONSENT LANDOWNERSHIP STATEMENT INSTRUCTIONS

The Non-Tributary Consent Landownership Statement (form GWS-3B) must be submitted with the well permit application in all cases where the well permit applicant believes or claims that water to be withdrawn is nontributary ground water or any ground water from the Dawson, Denver, Arapahoe or Laramie-Fox Hills aquifers, and the applicant for the well permit is not the owner of the land and the landowner has granted the applicant the right to withdraw such water as provided in Section 37-90-137(4)(b)(II)(A), C.R.S., or as provided in Rule 5.3.2.2 of the Designated Basin Rules, 2 CCR 410-1. The Statement must be signed by the landowner(s). The legal description and the number of acres of overlying land must be indicated. In areas of the State that are not surveyed, the State Engineer will accept an alternate description of the location of the overlying land sufficient to identify and locate the land. For legal descriptions of irregularly shaped parcels (where the boundaries do not follow or parallel section lines) or where there are exclusions of land within the total parcel, the applicant must submit a map having a scale of 1:24,000 or larger (e.g. 1:10,000) which accurately depicts the overlying land. If the legal description is too lengthy for the space provided on the Statement, please indicate "See attached legal description" in the space provided on the Statement and attach the complete legal description. The legal description and maps provided must be complete and legible. The aquifer from which ground water is claimed, must be indicated in the space provided. Where applications for more than one aquifer are submitted at one time, the applicant shall provide a separate Statement for each aquifer. Production from a well is limited to one aquifer only. In addition to this Statement, the applicant for a well permit claiming consent under the provisions of Section 37-90-137(4)(b)(II)(A), C.R.S., must complete and submit form GWS-3A. An applicant for a well permit claiming consent under the provisions of Rule 5.3.2.2 of the Designated Basin Rules must complete and submit form GWS-48.