Free Form 11 - Standard Variance Request From Rules Governing the Measurement of Ground Water Diversions Located in the Republican Ri - Colorado

FORM 11 ­ VARIANCE REQUEST
To: Division of Water Resources, (Republican River Basin) 1313 Sherman St. Rm. #818 Denver, CO 80203 Telephone: FAX: (303)866-3581 (303)866-3589

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CONTACT INFORMATION:
OWNER (IF CHANGED, PROVIDE "CHANGE IN OWNERSHIP/ADDRESS" FORM) Name: Address: City, State, Zip: Phone: E-Mail: USER (IF NOT SAME AS OWNER)

LOCATION AND INFORMATION OF WELL(S):
Must describe the location of the well(s) using either distances from section lines or GPS coordinates DWR Structure ID No.: Well Permit No.:
(if known)

Location; Distances from section lines, ¼¼, Section, Township, Range, PM

GPS COORDINATES OF WELL(S):
(FORMAT: UTM, DATUM: NAD 83)

SOURCE OF POWER TO WELL(S):
Electric................. Windmill............... Fossil Fuel (Gas, Propane, Diesel, etc.) ......... Other: Artesian............ Solar.................

WATER USE INFORMATION: IS THIS WELL(S)/PUMP(S) PRINCIPALLY USED FOR? .... Irrigation (includes agricultural and turf irrigation with untreated water) .... Other (Municipal, Commercial, or Other use)

FOR IRRIGATION WELLS ONLY:
Number of acres irrigated by this Well(s)/Pump(s) (or group of wells serving common acreage): Note: Reporting of less acreage than the quantity legally approved by
Water Court Decree and/or a well permit, does not constitute an abandonment or relinquishment of the unclaimed acreage. If the land area is irrigated by more than one well, please list the additional well permits involved:

Acres

Repub. River Basin Form 11

Updated: 04/01/08

FORM 11 ­ VARIANCE REQUEST
COMPLETE DESCRIPTION OF VARIANCE SOUGHT

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WELL OWNER

OR USER

CERTIFICATION:

The above information is true to the best of my knowledge. I agree to the release of information
pertaining to my use of electrical energy use to pump ground water, including CURRENT TRANSFORMER FACTOR, VOLTAGE/POTENTIAL TRANSFORMER FACTOR and ELECTRIC METER READINGS, to the COLORADO DIVISION OF WATER RESOURCES by my electric supplier for the purposes of determining or verifying WATER USE from the WELL(S) AND/OR PUMP(S) THAT ARE THE SUBJECT OF THIS VARIANCE REQUEST.

SIGNATURE OF WELL OWNER/USER:

DATE:

Repub. River Basin Form 11

Updated: 04/01/08

FORM 11 ­ VARIANCE REQUEST
DETAILED SKETCH: FOR IRRIGATION USE Draw a detailed map of the land irrigated by the wells/pumps. For all requests show total system from pump to discharge, other pumps or wells irrigating the same land, locations of any other structures on the land, etc.

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Repub. River Basin Form 11

Updated: 04/01/08