Form No. GWS-11 08/2016 COLORADO DIVISION OF WATER RESOURCES DEPARTMENT OF NATURAL RESOURCES 1313 Sherman St., Ste 821, Denver CO 80203 (303) 866-3581 dwrpermitsonline@state.co.us For Office Use Only CHANGE IN OWNER NAME/MAILING ADDRESS PRIOR TO COMPLETING THIS FORM, SEE INSTRUCTIONS ON REVERSE SIDE INCOMPLETE, POOR QUALITY, OR ILLEGIBLE FORMS CANNOT BE PROCESSED AND WILL BE RETURNED Name, address and phone number of person claiming ownership of the well permit: Name(s): Mailing Address: City, St. Zip: Phone: ( ) Email: Well Permit Number: WELL LOCATION: County: Receipt Number: Case Number (optional): Well Name or # (optional): Street Address at Well Location Check if well address is same as owner's mailing address 1/4 of the 1/4, Sec. , Township Ft. from N. or N. or S. Line, City State Zip S., Range E. or Ft. from , Lot W., E. or W. Line. , Filing/Unit P.M. Distance from Section Lines: Subdivision Name (if applicable): , Block NOTE: If changing/correcting the permitted location of a well, use Form No. GWS-42. I (we) claim and say that I am (we are) the owner(s) of the well permit described above, know the contents of the statements made herein, and state that they are true to my (our) knowledge. This filing is made pursuant to C.R.S. 37-90-143. Signature(s) of the New Owner Please print the Signer's Name & Title Date ___________________________________________ _________________________________________ _______________________ It is the responsibility of the new owner of this well permit to complete and sign this form. If an agent is signing or entering information, please see instructions. Please allow 4 to 6 weeks for processing of this form. Thereafter, you can view or print the accepted document at: http://www.dwr.state.co.us/WellPermitSearch Signature of DWR staff indicates acceptance as a Change in Owner Name and/or Mailing Address. For Staff Use Only _________________________________ Staff Signature _______________________ Date American LegalNet, Inc. www.FormsWorkFlow.com Form No. GWS-11 08/2016 INSTRUCTIONS FOR CHANGE IN OWNER NAME/MAILING ADDRESS FORM NO FEE IS REQUIRED NOTE ­ IF CHANGING/CORRECTING THE PERMITTED LOCATION OF A WELL, USE FORM NO. GWS-42 (APPLICATION FOR WELL LOCATION AMENDMENT). The form must be typed or printed in DARK INK. All changes on the form must be initialed and dated. INCOMPLETE, POOR QUALITY, OR ILLEGIBLE FORMS CANNOT BE PROCESSED AND WILL BE RETURNED. If filing online, refer to online form submittal instructions (http://water.state.co.us/groundwater/wellpermit/onlineformsubmittal) for further information. When filing online, you will need to save the completed form to create a PDF document and email the PDF document to: dwrpermitsonline@state.co.us. This form may be reproduced by photocopying or by computer means. GENERAL INSTRUCTIONS The form is to be completed by the well permit owner (the individual, company or entity claiming ownership of the well permit). Print the well permit owner's name and include their mailing address, phone number, and email address. Be sure to enter the Well Permit Number in the space provided. The Well Permit Number is required. If you do not know your well permit number, please contact our Records section at 303-866-3581 or Ground Water Information desk at 303-866-3587 for assistance. If the well does not have a Case Number, this field may be left blank. The Well Name or # is optional and is a designation provided by the well permit owner. Complete the well location information. If the physical address of the well location is different than the mailing address of the owner, include the physical address where the well is located. The actual well location must include ¼, ¼, Section, Township and Range. In most cases this information may be found on your well permit. Check the appropriate boxes for distance from section lines North or South and East or West directions. For wells located in subdivisions, the lot, block, and subdivision information must also be provided. The individual signing the application or entering their name (and title if applicable) must be the applicant or an officer of the corporation/company/agency identified as the applicant, or their attorney. An authorized agent may also sign or enter their name on the application if a letter signed by the applicant, or their attorney, is submitted with the application authorizing that agent to sign or enter their name on the applicant's behalf. Please allow 4 to 6 weeks for processing this form. Thereafter, you can view or print the accepted document at: http://www.dwr.state.co.us/WellPermitSearch. A copy of this form will not be mailed or emailed to you. If you have questions, contact the Denver Office or the Division Office where the well is located. Contact information is available from our website at: http://water.state.co.us/Home/ContactInfo American LegalNet, Inc. www.FormsWorkFlow.com