2010-11-05_GENERAL DOCUMENTS - C2009087

• Permit No: C2009087
• IBM Index Class Name: General Documents
• Doc Date: 11/5/2010
• Doc Name: Well Permit ‎(Emailed )‎
• From: Colorado Division of Water Resources
• To: DRMS
• Permit Index Doc Type: Other Permits
• Email Name: JDM
• Media Type: D
• Archive: No

Form
No. GWS-7 EXEMPT PERMIT INFORMATION SHEET
612009 STATE OF COLORADO
OFFICE OF THE STATE ENGINEER
821 Centennid Bkf.,1313 Sherman St. Denver, Colorado 80203
[phone] Fact (303) 88845891
INFORMATION FOR WELL PERMITS APPROVED PURSUANT TO CRS 37-924102
(HOUSEHOLD. DOMESTIC. LIVESTOCK AND EXEMPT COMMERCIAL USES)
Caref ily read the conditions of approval on your wall p mm k The =ndNkm and the infbrmaton on this
lefonnation sheet must be corrhpled with in order for the permit to remain valid
THE PERMIT EXPIRA DATE M TIM YEARS FROM THE DATE HUED, The wall mud be constricted and
evidence of We construction mud be recelvsd by this office in the form of a well Construction and Tat report tom
the wall construction contractor confirming that the well was constructed prior to ax*stlon of the wed permit. The
wag permit number is located in the upper right hand comer of the permit, and the expiration date is located In the
lower right hand comer. The expiration dab of the permit may be extended one year st a time at the discretion of
to State Engineer, for good cause shown. K an extension of time Is necessary to construct the wed„ a written
request br the extension of time must be received by this office prior to the expiration dab of the well
permit in the request, you must provide the well permit number, your name and mail" address and the
reasons why the well has not been constructed and approxinably when it will be constructed.
Water well construction and pump indeleft corntractors are specifically licensed in Colorado to perform these
specialized tasks. it is Mogul ter contractors who do not hold these Bconew to construct wells andlor Natal pumping
equipment in or on wells. The wed mud be constructed and the pump Installed by contractors with current
i1cense(s) issued by the Stile of Colorado unless exampted as described on the reverse side. Please ssk to see
their licenso(s). Ba cMwe Operators and Licensed Plumbers may or may not hold the respective Well Construction
and/or Pump Irwhistioh iiowmm Please be aware of this when you contract to construct the well and instep
pumping equipment. The well construction report including a ted of the well yield must be submitted to the office of
the Stab Engineer within ably (60) days of completion of the work or within seven days after eooutlon of the
permit whMww is earlier. The pump Installation report including a pumping system test mud be submitted within
sbdy (80) days of compMm of the work. The contractor(s) must provide you with a copy of the work report(s) fled
with the State Engineer. The Wei Construction and Ted Report. Form Number GWS-31 and the Pump Installation
and Teat Report. Form Number GWS-32 are available torn the' Division of Wafer Resources offices. Additional
Information regarding well construction. pump Installation, required testing and well plugging end sealing regulations
are found on to reverse side of this sheet
You have been provided with at least two copies of the well permit Keep a copy ter your records. There Is
also a copy for the pump installation contractor. Copes have been sent to the driller If you Indicated a driller
Boerne number on the application, or two additional copies have been enclosed You may make additional
copies for the wag construction contractor if you select one different from the one indicated in your application.
The original permit Is on file in the Denver office Records Section. Copies may be obtained for a The of 50 cents per
pails. Ststurtes require that any change of maiing address or ownership be reported to the State Engineer. Form
number GWS-11 Is used both by new owners to report ownership changes and current owners to report address
changes.
If you have questions, contact the Denver Office, or the Division Office in the area wheys your wall is located.
0 U 4
810 IP SL 2w Floor Abdendo Ave Ste B
311 1 Mugft Me
30 1 871 East
Main St
Greeley. CO 80631 Pueblo, CO 81004 Alamosa. CO 81101 Montroa. CO 81401
[phone] (7191) 542.3388 (710) 5898683 (870) ?49-8822
Fax !70 3021818 Fat 191 844-0800 Fax 19 5W8885 Fax [phone]
o dw 5 Dhrision 6 Diriebh 7 Denver oMloe
Direct real to Boot 3918 Direct real to Box 773450 160 Rodt Point Dr.. Ste. E 1313 Sheman St Rm. 818
Glenwood 8pgs CO 81602 505 Anglers Dr. Sub 101 Dw ngo, CO 81301 Der, ver. CO 80203
50833 U.S. Fishy 6 8 24 Steamboat Spgs, CO (9170) 247-1845 [phone]
Gisnwood Spgs., CO 81801 80477 Fat [phone] Fax [phone]

F PM
ax (OM) 41 Cal Net Fox(9i70 070