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FORM 11 ­ VARIANCE REQUEST
To: Division Engineer, Water Division No. 3 P.O. Box 269 301 Murphy Drive Alamosa, CO 81101 Telephone: FAX: (719) 589-6683 (719) 589-6685

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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 Case No. and DWR Structure Decreed ID No.: Structure Name: (if known)

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

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

Well Permit No.:

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.

Acres Yes ....... No .......

Is the acreage served by this well/pump irrigated with groundwater only? If No, what is the source (ditch name) and amount (cfs or shares) of the surface water?

Div 3 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:

Div 3 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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Div 3 Form 11

Updated: 04/01/08