Free GWS-22, REQUEST FOR EXTENSION OF EXPIRATION DATE - Colorado

Form No. GWS-22 6/2006

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

REQUEST FOR EXTENSION OF EXPIRATION DATE
For well permits issued pursuant to C.R.S. 37-90-137(4) only.

Insert the Well Permit Number
Well permittee information:

_________________________.

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

Phone (

) __________________________

Estimated date of well completion: ___________________________________. Statement of good cause why the well has not been completed: _____________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ . 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.
Signature(s) ____________________________________ ____________________________________ Please print the Signer's Name & Title _____________________________________ _____________________________________ ____________________ Date

INSTRUCTIONS: This form is for use concerning well permits approved pursuant to the provisions of Colorado Revised Statutes 37-90-137(4). If the well will not be constructed prior to the expiration date, this request for extension must be received prior to the permit expiration date, and must be accompanied by a filing fee of $60.00. Type or print neatly in black ink. This form may be reproduced by photocopy or word processing means.

For Office Use Only