Free 21contnotif.PDF - Colorado

Form No. GWS-21 5/00

STATE OF COLORADO OFFICE OF THE STATE ENGINEER
818 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 (303) 866-3581 Fax (303) 866-3589

For Office Use Only

NOTIFICATION OF DRILLING CONTRACTOR

Insert the Well Permit Number
Well permittee information:

_________________________.

Name(s) ____________________________________________________ Mailing Address _______________________________________________ City, St. Zip ___________________________________________________

Phone (

) __________________________

The licensed well construction contractor or private driller who will construct the well authorized under the permit number indicated below is or has been changed to: Name of Contractor _______________________________________________________________ License number _________________. The anticipated date of beginning well construction is ______________________________.

I (we) claim and say that I (we) (are) the owner(s) of the well described above and that the statements made herein are true to my (our) knowledge.
Please print the Signer's Name & Title ____________________________________ ____________________________________ Signature(s) _____________________________________ _____________________________________ ____________________ Date

INSTRUCTIONS: This form is for use concerning well permits approved pursuant to the provisions of Colorado Revised Statutes 37-90-137(4). It must be filed 10 days prior to commencement of construction of the well as required by Statewide Nontributary Ground Water Rule 5A(12). Type or print neatly in black ink. This form may be reproduced by photocopy or word processing means.

For Office Use Only