Form No. GWS-11 6/2006 For Office Use Only STATE OF COLORADO OFFICE OF THE STATE ENGINEER 818 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 Phone – Info: (303) 866-3587 Main: (303) 866-3581 Fax: (303) 866-3589 http://www.water.state.co.us CHANGE IN OWNERSHIP/ADDRESS CORRECTION OF THE WELL LOCATION Review instructions on the reverse side prior to completing the form. Name, address and phone of the person claiming ownership of the well: NAME(S): Mailing Address: City, St. Zip: Phone ( ) This form is filed by the named individual/entity claiming that they are the owner of the well permitted as referenced above. This filing is made pursuant to C.R.S. 37-90-143. WELL LOCATION: Well Permit Number: Receipt Number: County Owner’s Well Designation (optional) (Address) 1/4 of the (City ) 1/4, Sec. , Twp. Distance from Section Lines: Subdivision Name N. or Ft. From N. or S., Range S., Lot (State) E. or W., P.M. Ft. From , Block (Zip) E. or W. Line. , Filing/Unit The above listed owner(s) say(s) that he, she (they) own the well described herein. The existing record is being amended for the following reasons: Change in name of owner Change in mailing address Correction of location for exempt wells permitted prior to May 8, 1972 and non-exempt wells permitted before May 17, 1965. Please see the reverse side for further information regarding correction of the well location. I (we) claim and say that I (we) (are) the owner(s) of the well described above, know the contents of the statements made herein, and state that they are true to my (our) knowledge. 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 to complete and sign the form. Signatures of agents are acceptable if an original letter of agency signed by the owner is attached to the form upon its receipt. For Office Use Only _________________________________ State Engineer _________________________________________ By _______________ Date American LegalNet, Inc. www.FormsWorkFlow.com Form No. GWS-11 6/2006 INSTRUCTIONS CHANGE OWNERSHIP-ADDRESS-LOCATION CORRECTION FORM NO FEE IS REQUIRED The form must be typewritten or printed in BLACK OR BLUE INK. Initial and date any changes you make on the form. THIS FORM MAY BE REPRODUCED BY PHOTOCOPYING OR WORD PROCESSING MEANS. INCOMPLETE FORMS WILL BE RETURNED. Be sure to include the well permit number in the space provided under the section titled “Well Information”. The form is to be completed by the well owner (the individual, company or entity claiming ownership of the well). Print the well owner's name and include the mailing address and phone number. Complete the well location information. The Owner’s Well Designation is optional and is a designation (e.g. number, name) provided by the well owner. If the address of the well location is different than the mailing address of the owner, include the address where the well is located. The actual well location must include ¼, ¼, Section, Township and Range. Check the appropriate boxes for North or South and East or West directions. Complete the Subdivision, Lot, Block and Filing information, if applicable. Indicate in the appropriate boxes if the form is submitted to change the ownership and/or address, or both. The individual, company or entity claiming ownership of the well must sign the form. Sign the first block and date the last block. If you are signing as a representative of a company who owns the well, then your title must also be included in the second block. USE THIS FORM TO CORRECT THE LOCATION OF YOUR WELL IF: A. Your well was permitted, registered, or first used prior to May 8, 1972 for ordinary household purposes in up to three single-family dwellings, fire protection, the watering of poultry, domestic animals, and livestock on farms and ranches and the irrigation of not over one acre of home gardens and lawns. B. Your well is not of the type described in A above, but was permitted or registered prior to May 17, 1965. Inside the Designated Ground Water Basins, other procedures and publication may be required. C. Your well was decreed by the Water Court for the correct location. IN ALL OTHER CASES USE FORM GWS-42 (CORRECTION OF WELL LOCATION FORM). If you have questions, contact the Denver Office or the Division Office where your well is located. Contact information is also available from our website at http://www.water.state.co.us. American LegalNet, Inc. www.FormsWorkFlow.com