JDF 298Wb 5-15 APPLICATION FOR UNDERGROUND WATER RIGHT FOR EXEMPT WELL AND CERTIFICATE OF NOTICE Page 1 of 6 251 2013, 2014, 2015 Colorado Judicial Department for use in the Courts of Colorado D istrict Court, Water Division , Colorado Court Address : CONCERNING THE APPLICATION FOR WATER RIGHTS OF Applicant: In the River or its Tributaries In COUNTY COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E - mail: FAX Number: Atty. Reg. #: Case Number: Division: Courtroom: APPLICATION FOR CONDITIONAL ABSOLUTE UNDERGROUND WATER RIGHT FOR AN EXEMPT WELL PURSUANT to 247 37 - 92 - 602(4), C.R.S. Section 37 - 92 - 602(1), C.R.S. states that Article 92, Water Right Determination and Administration, does not apply to a number of types of wells, including: w ells not exceeding fifteen gallons per minute of production and used for ordinary household purposes, fire protection, the watering of poultry, domestic animals, and livestock on farms and ranches and for the irrigation of not over on e acre of home gardens and lawns but not used for more than three single - family dwellings; w ells not exceeding fifteen gallons per minute of production and used for drinking and sanitary facilities in individual commercial businesses; w ells to be used exc lusively for fire - fighting purposes if said wells are capped, locked, and available for use only in fighting fires; and w ells not exceeding fifty gallons per minute that are in production as of May 22, 1971, and were and are used for ordinary household pur poses for not more than three single - family dwellings, fire protection, the watering of poultry, domestic animals, and livestock on farms and ranches, and for the irrigation of not over one acre of gardens and lawns . 247247 37 - 92 - 602(1)(b) - (e), C.R.S. However, p ersons who have or intend to apply for an exempt well permit, may also apply for a water right pursuant to 247247 37 - 92 - 302 to 37 - 92 - 602, C.R.S. See 247 37 - 92 - 602(4), C.R.S. Persons should not apply for a water right for an exempt well until they hav If applicant is applying for an underground water right and the source is either nontributary or a Denver Basin aquifer, Applicant should use Form JDF298W or JDF308W, respectively as appr opriate. the location for each structure in this application. UTM coordinates ( for example from a GPS device ), or measured distances in the field from known section lines are acceptable. The Division Engi neer, the Water Referee, or the Water Judge, may order the applicant to confirm the location of any structure with UTM coordinates, a survey, or other method. 1. Name, mailing address, email address, and telephone number of applicant(s) (if there are multiple applicants, and the space provided is not adequate to list all of the applicants, the names, addresses, telephone numbers and available email addresses must be provided as an attachment): Name of Applicant Mailing Address Email address T elep hone Number American LegalNet, Inc. www.FormsWorkFlow.com JDF 298Wb 5-15 APPLICATION FOR UNDERGROUND WATER RIGHT FOR EXEMPT WELL AND CERTIFICATE OF NOTICE Page 2 of 6 251 2013, 2014, 2015 Colorado Judicial Department for use in the Courts of Colorado 2. Name(s) of well(s) and permit, registration, or denial number(s). Attach copies of well permit, pump installation report and well construction and test report. (If permit applied for, but not acted upon, give date of permit application.) Name of Well Permit, Registration, or Denial Number If Permit is pending, check box below and provide date of application. Date: Date: Total area of parcel on which this well is located square-feet acres 3. Legal description of well: Location information in UTM format (Preferred): UTM Zone must be 12 or 13; Units must be Meters; Datum must be NAD83; and Units must be set to true North. Include the source of the UTM coordinates, for example: GPS device; a GIS System such as DWR AquaMap or CDSS MapViewer; scaled from USGS topographic map; or other source. In areas having generally recognized street addresses, also include street address, and if applicable, the lot, block, and subdivision. Attach a legible 8 275 x 11 inch map to this application illustrating location of the structure. UTM coordinates East ing North ing Zone 12 Zone 13 Street Address: Subdivision: Lot Block Source of UTMs ( for example, hand - held Garmin GPS): Accuracy of location displayed on GPS device ( for example , accurate to within 200 feet): Legal Description Using the Public Land Survey System (PLSS) (Optional; Please include both UTM and PLSS descriptions if known): Include perpendicular distances from section lines, and indicate 274 274, section number, township, range, meridian and county; mark the location of the structure on a USGS topographic map and attach to this application a legible 8 275 x 11 inch copy of the applicable portion of the map. In areas where section lines have not been established, a bearing and distance to an established government monument is acceptable. Include the source of PLSS information, for example: GIS System such as DWR AquaMap or CDSS MapViewer; field survey; scaled from a USGS topographic map; or other source. In areas having generally recognized street addresses, also include street address, and if applicable, the lot, block, and subdivision. Legal Description: County 1/4 of the 1/4 Section Township N or S Range E or W Principal Meridian Distance from section lines (not from property lines) Feet from N S and Feet from E W Source of PLSS information: Street Address: Subdivision: Lot Block American LegalNet, Inc. www.FormsWorkFlow.com JDF 298Wb 5-15 APPLICATION FOR UNDERGROUND WATER RIGHT FOR EXEMPT WELL AND CERTIFICATE OF NOTICE Page 3 of 6 251 2013, 2014, 2015 Colorado Judicial Department for use in the Courts of Colorado 4. A. Date of appropriation: B. How appropriation was initiated (for example, the date that the well permit application was filed with the : C. Date water applied to beneficial use (for example, the date that the applicant first operated the well for its intended use): 5. A. Source of water (for example, groundwater tributary to the South Platte): B. Depth of well, if completed: 6. Amount of Underground Water claimed in gallons per minute (gpm): Conditional ( gpm) Absolute ( gpm) 7. List All Existing Uses (such uses cannot exceed the uses permitted under the exempt well permit): A. Number of single-family dwellings served B. Area of lawns and gardens irrigated square-feet acres Legal description of irrigated acreage. Mark the location of the irrigated acreage on a USGS topographic map and attach to this application a legible 8 275 x 11 inch copy of the applicable portion of the map. C. Domestic animals watering Yes No D. Livestock watering on farm/ranch/pasture (property must be 35 or more acres) Yes No E. Other uses (describe fully): 8. Proposed Uses (Note that this information is only required if the applicuses allowed by the exempt well permit and the applicant is seeking a conditional water right for such additional uses.) A. Number of single-family dwellings served B. Area of lawns and gardens irrigated square-feet acres C. Domestic animals watering Yes No American LegalNet, Inc. www.FormsWorkFlow.com JDF 298Wb 5-15 APPLICATION FOR UNDERGROUND WATER RIGHT FOR EXEMPT WELL AND CERTIFICATE OF NOTICE Page 4 of 6 251 2013, 2014, 2015 Colorado Judicial Department for use in the Courts of Colorado D. Livestock watering on farm/ranch/pasture (property must be 35 or more acres) Yes No E. Other uses (describe fully): 9. Name(s) and address(es) of owner(s) or reputed owners of the land upon which any new or existing diversion or storage structure, or modification to any existing diversion or storage structure is or will be constructed or upon which water is or will be stored, including any modification to the existing pool. The applicant must notify these persons that the applicant is applying for this water right, and certify to the Court that the applicant has done so by no later than 14 days after filing this application. The certification form is on page 5 of this form. Name of Owner Mailing Address 10. Remark