Form No. GWS-12 6/2012 STATE OF COLORADO OFFICE OF THE STATE ENGINEER 1313 Sherman St., Room 821, Denver, CO 80203 Main: (303) 866-3581 Fax (303) 866-3589 DWR Website: www.water.state.co.us Email to: dwrpermitsonline@state.co.us For Office Use Only REGISTRATION OF EXISTING WELL Review form instructions prior to completing form NAME & CONTACT INFORMATION OF WELL OWNER: Name(s) Mailing Address City: Phone No. with area code WELL LOCATION County: (Address) 1/4 of the 1/4, Sec , Twp Ft. N.or N. or S. Line, S., Range Ft. State: Email Zip Code: Well Name(optional): (City ) E. or E. or W., W. Line. (State) P.M. (Zip) Distance from Section Lines ATTACH A COPY OF A CURRENT DEED FOR THE SUBJECT PARCEL Subdivision Name ____________ __ Lot______ Block_____ Filing/Unit Easting Northing Optional: GPS well location information in UTM format. The following GPS settings are required: Format must be UTM. Units must be in meters. Datum must be NAD83. Unit must be set to true north. Zone 12 or Zone 13 Was GPS unit checked for above items? YES NO The well has historically been used for the following purpose(s): Water first used beneficially by the original owner for the above described purposes on (mm/dd/yyyy) The total depth of this well is The pumping rate of this well is The average annual amount of water diverted is The lawn and garden irrigated (watered) by water from this well is Number The making of false statements herein constitutes perjury in the second degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S. 23-3-104(13)(a). I have read the statements herein, know the contents thereof, and state that they are true to my knowledge. Sign or enter name of Well Owner(s) Print Name and Title of Well Owner(s) Date (mm/dd/yyyy) feet. gallons per minute. acre-feet. Acre or Square feet. . For Office Use Only WE WR CWCB AQUA MYLAR Div WD Basin MD American LegalNet, Inc. www.FormsWorkFlow.com REGISTRATION OF EXISTING WELL APPLICATION INSTRUCTIONS GWS-12 (6/2012) Please type or print legibly in black or blue ink. Applications may be faxed, mailed or submitted by email to: dwrpermitsonline@state.co.us Incomplete forms are not acceptable and will be returned. Attach additional sheets if more space is needed. For additional information concerning filing online please go to the DWR Website at: www.water.state.co.us Certain wells not previously registered or permitted may be registered pursuant to C.R.S. 37-92-602(5) or 37-90-105(4). The wells must have been constructed and put to beneficial use prior to May 8, 1972. The types of wells that may be registered are identified as follows: 1) Wells not exceeding fifteen gpm which are used for ordinary household purposes, fire protection, the watering of poultry, domestic animals and livestock on farms and ranches, the irrigation of not over one acre of home gardens and lawns, but not used for more than three single family dwellings. Wells not exceeding fifty gpm which were in production as of May 22, 1971, and were and are currently used for purposes not exceeding those described in (1) above. Wells not exceeding fifteen gpm, which are used for drinking and sanitary facilities in individual commercial businesses. Wells used exclusively for fire-fighting purposes if the wells are capped, locked and are used only in fighting fires. Wells within Designated Groundwater Basins may be registered provided they do not exceed 50 gpm and are used for not more than three single family dwellings and the irrigation of not over one acre of home gardens and lawns, the watering of livestock on range and pasture, or use in one commercial business. If you are uncertain as to whether or not the existing well was previously registered or permitted you may contact our Records Section at 303-866-3581 for assistance with well permit research. FEES: The filing fee for this Form No. GWS-12 application is $100. If an application for a permit to replace the old existing well in the same aquifer (Form No. GWS-44 or 45) is submitted along with Form No. GWS-12, then the combined filing fee is $100. Fees are nonrefundable. Acceptable forms of payment are check or money order payable to the Colorado Division of Water Resources. Payment by Visa, MasterCard or Discover cards can be accepted by phone through the Records Office at 303.866.3581. INSTRUCTIONS: Print the well owner's name and include the mailing address and phone number including area code! If 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 designation, section #, township, range, principal meridian, and distances from section lines. Mark the appropriate boxes for North or South and East or West directions. (An option to providing distances from section lines is to provide a GPS location (UTM coordinates). The required GPS settings must be as indicated on the front of this form. If providing a GPS location, the ¼, ¼ section designation, section number, township, range, and principal meridian must still be provided.) Colorado contains two UTM zones (12 & 13). Zone 13 covers most of th th Colorado. The boundary between Zone 12 and Zone 13 is the 108 Meridian (longitude). West of the 108 Meridian is UTM Zone 12 and th th east of the 108 Meridian is UTM Zone 13. The 108 Meridian is approximately 57 miles east of the Colorado-Utah state line. On most GPS units, the UTM zone is given as part of the Easting measurement. Check the appropriate box for the zone. Attach a current deed for the subject parcel. If filing via email please see online instructions for how to submit deed or legal description attachments. Describe the use(s) to which the water has actually been applied. If you are also applying to install a rooftop precipitation collection system, complete Form No. GWS-78 and submit it with this application. No additional filing fee is required. Enter the date of first beneficial use by the original owner. This date must be prior to May 8, 1972, to register a well under this law. Any expanded use of the well that occurred on or after May 8, 1972, or any use that has been abandoned by 10 or more consecutive years of non-use, cannot be included in this application and does not qualify for registration. Enter the total depth of the well. Enter the pumping rate of the well in gallons per minute. The annual amount of water diverted in acre-feet must be indicated. One acre-foot is equivalent to 325,851 ga