Free Form No - Colorado

Form No. GWS-19 01/2005

STATE OF COLORADO GROUND WATER COMMISSION DIVISION OF WATER RESOURCES
818 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 (303) 866-3581 Fax (303) 866-3589

For Office Use Only

NOTICE OF COMMENCEMENT OF BENEFICIAL USE
For well permits issued pursuant to CRS 37-90-107(7) or 37-90-111(5)

Insert the Well Permit Number ________________________.
Well Owner Information: Name(s): _____________________________________________________. Mailing Address: _______________________________________________. City, State, Zip: ________________________________________________. Phone: ( ) __________________________________________.

WELL LOCATION: County _________________________ Owner's Well Designation _______________________ _____1/4 of the______ 1/4, Section ______, Township _______
Distance from Section Lines: _________feet from
North or

North or

South, Range _______ West of the Sixth P.M.
East or West, section lines.

South, __________ feet from

Date of first beneficial use of ground water from the well: ___________________________________________. Initial type of beneficial use(s): ________________________________________________________________ I (we) claim and say that I (we) am (are) the owner(s) of the well described above and that the commencement of beneficial use of ground water from this well, lawfully made under the subject well permit, first occurred on the date indicated; and that the statements made herein are true to my (our) knowledge. This notice is flied in accordance with CRS 37-90-108(2)(d). Please print the signer's name & title: Signature(s) of the well owner(s): Date:

____________________________________ ____________________________________

____________________________________ ____________________________________

_______________ _______________

INSTRUCTIONS: This notice is required for all wells withdrawing ground water under permits issued by the Colorado Ground Water Commission, for the Dawson, Denver, Arapahoe, or Laramie-Fox Hills aquifer, pursuant to CRS 37-90-107(7) or 37-90111(5), and must be filed with the Division of Water Resources within 30 days after commencement of beneficial use. Please type or print neatly in black ink. This form may be reproduced by photocopy or word processing means.
For Office Use Only