2003-09-05_REVISION - M1986076 ‎(2)‎

• Permit No: M1986076
• IBM Index Class Name: Revision
• Doc Date: 9/5/2003
• Doc Name: Response
• From: SEO
• To: DMG
• Type & Sequence: AM3
• Media Type: D
• Archive: No

INSTRUCTIONS FOR THE COMPLETION OF STATEMENT OF BENEFICIAL USE
IMPORTANT INFORMATION: If the permit was approved pursuant to C.R.S. 37-90-137(2), the Statement of Beneficial Use must
be received by the state engineer prior to the expiration of the permit. If the permit was approved pursuant to C.R.S. 37-90-107,
the statement of beneficial use must be received within three years from the date the permit was issued.
NOTE: If the permit was approved pursuant to C.R.S. 37-90-137(4), then you must use form no. GWS-18 "Notice of Well Completion" and
form no. GWS-19 "Notice of Commencement of Beneficial Use".
The Statement must be typewritten or printed in BLACK INK Initial and date any changes you make on the form.
INCOMPLETE FORMS ARE NOT ACCEPTABLE AND WILL BE RETURNED. ATTACH ADDITIONAL SHEETS IF MORE SPACE IS
NEEDED.
NO FEE IS REQUIRED IF THE STATEMENT IS SUBMITTED TIMELY. IF NOT SUBMITTED TIMELY, A FEE MAY BE REQUIRED.
The Well Permit Number must be indicated in the space provided at the top of the form.
Print the well owner's name and include the mailing address and phone number.
If the well location is different than the mailing address of the owner, include the address where the well is located. If the owner has
more than one well, provide well name or number as designated by the owner; i.e. North Well. The actual well location must include 1/4,
1/4, Range, Township, Section and distances from Section lines. Mark the appropriate boxes for North or South and East or West
directions.
Describe the use(s) to which the water has actually been applied. Permitted uses are described in the conditions of approval of the
permit.
Enter the date of first beneficial use. This is the date water from the well was first used beneficially the purposes described under the
approved permit indicated. The date claimed cannot predate the issuance of the permit. It is not the date the form is completed, nor
is it the date the well was test pumped.
Enter the pumping rate claimed. The rate cannot exceed the permitted maximum rate or the actual pumping rate in gallons per
minute, whichever is less: 449 gallons per minute is equivalent to one cubic foot of water per second.
Enter the annual amount of water diverted in acre feet. The amount claimed cannot exceed the physical capacity of the well or the
permitted amount as limited by any conditions of approval. One acre foot is equivalent to 325,900 gallons. An ordinary home with lawn
and garden irdgation diverts an average of less than one acre foot. Average in house use which does not include lawn and garden
inigation (watedng) diverts 1/3 acre foot.
Report the area irrigated either as acres or square feet by filling in the correct number and checking the appropriate box. You must
describe the specific area irrigated using either the legal description of that land or by referencing the Subdivision, Lot, Block and Filing
or Unit number. Lawn and garden watering is considered irrigation. If the well is not used for irrigation, place a zero in the
acres/square feet irrigated blank. One acre is 43,560 square feet. One acre foot is 43,560 cubic feet of water.
Indicate the Well Construction and Pump Installation Contractors and their License Numbers. If you did the work yourself, report
this by indicating owner or sell in the license number area You must submit work reports if you constructed the well and/or installed the
pump.
If a totalizing flow meter is required as a condition of the permit, indicate the meter manufacturer name, it's serial number and the date
of installation.
The well owner must sign the Statement. Print or type your name in the first block if it is different from Item No. 1. If signing as a
representative of a company who awns the well, then your title must also be included in the first block. Sign the second block and date
the last block.
If you have questions, contact the Denver or the Division Office where your well is located.
Division 1 Division 2 Division 3 Division 4
810 9s' St. 2ntl Floor 310 E. Abriendo Ave Ste B 301 Murphy Drive 1871 East Main St.
Greeley, CO 80631 Pueblo, CO 81004 Alamosa, CO 81101 Montrose, CO 81402
[phone] [phone] [phone] [phone]
Fax [phone] Fax [phone] Fax [phone] Fax [phone]
Division 5 Division 6 Division 7 Denver Office
Direct mail to Box 396 Direct mail to Box 773450 701 Camino Del Rio Ste. 205 1313 Sherman St. Rm.
Glenwood Spgs CO 81602 505 Anglers Dr. Suite 101 Durango, CO 81301 818
50633 U.S. Hwy 6 & 24 Steamboat Spgs, CO 80477 [phone] Denver, CO 80203
Glenwood Spgs, CO 81601 [phone] Fax [phone] [phone]
[phone] Fax [phone] Fax [phone]
Fax [phone] Call First