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NOV -20 -2002 09:5&A FRW' EXEMPT PERMIT INFORMATION SHEET <br />ajVw STATE OF COLORADO <br />OFFICE OF THE STATE ENGINEER <br />621 CeMennial Bid¢., 1313 Shaman SL: Denver, Cobrado 60203 <br />(303) 866 -3581 Fax (303) NS -3589 <br />INFORMATION FOR WELL PERMITS APPROVED PURSUANT TO CRS 3T -Q-602 <br />(HOUSEHOLD, DOMESTIC. LIVESTOCK AND EXEMPT COMMERCLAL USES) <br />The cor%tions of appCoval on Vie veil permit end the irdomration on this wduffnallm sheet nwst be complied with in order for the <br />permit to mrnein WSW- a is not racwswy to sttff * a BEeomer t of 8enefioi i Use br ftus type of wee permit <br />13 . The well must be MM&uCbd and evidenoe of <br />ICs conatrt cbM must be received by fhis office in the corm of a well Corte ruction and Test ,sport from the well con u=n <br />oonbr�ebr oortftnrdng that dta weO was cw trudW erior•�gi la d M of the welt pamvt The well permit number is boated into <br />upper right hares caner of ffre pem The expint+tion date of <br />the PenrA nay be extended one year eta time of tt►e diva bon of the Sims Errgirteer for good cause tlh - If an <br />eMftiiM Of titne Is nertissary to Consbvct the waft, t watt to rogtmt for Me extension of time must be <br />recetwed by this tNNoe prior to the expfradon date of go won pwMjL in the reques% yar must Rr"We gn <br />weft permit number, Your name and mafta addma and the reason why dw well has not been construeW <br />and when it will be cww&uctad. No fie is requkud for thin type of pent* extension. <br />WOW Wien COnSillUction std Bump Mftffatbn contreows are speahcal y fi mwd in Ccl redo b peftm ttwse speciaiZed <br />tWW& It is Nagel for canbaMm who do not hold f iese licenses m ConsbW wells srrdfor install pumping equomer t in a an <br />web. The wee Mtge be oonOuceed and Res pump inataW by cwWadom we cvrrtnt Wense(s) issued by Ih8 Sfaee of Coror�sdo <br />ur>fess exenww as descit wl on the reverse side Presse auu to am their tic mWe)- 6sckhoe Oper>abors and Ucsnsed <br />PILUMSM MIRY Of tfwy not hold Um respoWn Wei Contraction andior Pump Installation s licenses Plasss be aware <br />Of DO when you Millract b ca MUW the well and install pumping wppment . The web conWu=n report i u*4rtg a lest of the <br />well yield must be submMed ID the d5w of Mrs Shm Erpineer wom sixty (60) days of completion of the wort or within seven <br />days aft txpirakn of Me permit• whichever a eaAer The pump lnsieMAW report 'etcWrfirrg a Pt rWV $yatsm iest moat be <br />subnrltied wig saagl (60) days of completion of She wait The cateractoKs) must pin vide you with a oopy of the work reports) <br />MW with the Stale 6rgineer. The We# CoMmAdlon and Tsst Report, Form Nurnbrr MUS-31 and Mte Pump Irlst dale and Tess <br />Report, Form NumW GYPS -32 are avabbte !from the Olvivon of WWer Resouroee oft es Add bon; l irdornudion regarding wel <br />coy *Vucbw, p.W* insUftfi n. mxpw O t'aslira tend wen p "ing and sewl+ng regWowns are toured on Vw reverse We of Va <br />it+eet <br />You Mw been provfQed wlm copies of the W44 permit. The owners COW 161Ox YOW ^QOAJS- Trwe is 2160 a copy for the <br />Pmp motion carftclm. If you do not leceive the dril 3 Copy, t hts been mailed W the dOw you f 4cMd on your <br />apple W=- YOU may Matte addbnng a0gas for the well dnT& d you sled a ddfererd NWMdLOk The Dmwon does not requm <br />you to nattfy Us M a dtf erw t aonlractor is selechxt DO NOT r-W UP YOUR " O WER'S COPY" TO THE CONTRACTOR. <br />The orlgiral permit is on fle in the Denver of W Reaorda Seclion. CoPM may bs d0twned tar a be or So cants vet DWe- <br />SUMAes saquire that any Change of rcruWq address Cr arnwar4p be teaorted b the Stabs Engs>eer Form number GINS -11 is <br />used both by new owners b report owners* Owxp s and turret vwnars b repot address cnangee. <br />if you have questions, contact vw Denver Office. or !fie Div WW Office in ties area where your wen is located. <br />Division 1 <br />810 V St 2" Floor <br />OA <br />�1 <br />Division 2 <br />310 E. AWwldo live Sat: 8 <br />,co81o04 <br />Vs <br />9 t . <br />cool, <br />a1ZO5' _..e Std <br />♦Divisfpr<�+3� <br />422 a St <br />A}a W' C08'10' <br />n19) <br />Fay( (T19 <br />�414 c go <br />5 <br />0101 dt01 <br />Division 4 <br />1540 E wacem <br />N(ortttxse. CO 814022 <br />(gT0) 2AQ4622 <br />Ftlrx (9 <br />Demw o St ftm s,8 <br />1313 qa;3 <br />0�.6a, `___� <br />idA <br />ZAN <br />