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Form No <br />GWS -68 <br />10/2011 <br />EXISTING WELL INFORMATION AND INSPECTION FORM <br />Division of Water Resources, 1313 Sherman St., Ste 821, Denver, CO 80203 <br />PLEASE COMPLETE THIS FORM IN BLACK INK <br />PERMIT NO: RECEIPT NO: DIV: WD: <br />Existing Well Location: 1 /4 of the 1 /4, Sec. , Twp , Rng <br />P.M. <br />feet from N/S sec. line, feet from the E/W sec. line; County <br />Existing well owner: Name: <br />Mailing Address: <br />City /State /Zip Telephone: ( <br />Description of parcel (subdivision, lot, bik, flg) Size ac <br />Existing well location and visual conditions: If stating no, please explain <br />Type of Existing Well: Drilled, Hand Dug, Spring Well, Gallery Well, Gravel Pit, Other <br />Distance to nearest septic tank /sewer line (approximate) feet <br />Distance to nearest leach field (approximate) feet <br />Is the well in a clean and sanitary location? <br />Is the well maintained in a clean and sanitary condition? <br />Is the ground at the surface sloped away from the well for proper drainage? <br />Is the surface surrounding the well firm and stable? <br />Is the well situated in a well house or vault? If so, is the well house or vault in good repair <br />and condition? <br />Existing well construction and materials: If stating no, please explain <br />Is the well equipped with a sanitary well seal /cap? <br />Is the well constructed with steel casing at the surface? <br />Does the casing extend at least one (1) foot above the surface? <br />Casing size in; Estimated well depth feet <br />Who constructed well? ; Who installed pump? <br />Current uses of existing well: Were the existing uses initiated prior to May 8, 1972? <br />Household use in single - family dwellings <br />Watering of poultry and /or domestic animals <br />Watering of livestock on farm or ranch; approximately how many head? <br />Is this a feedlot? ; How many head? <br />Lawn and /or garden square feet <br />Crop Irrigation acres <br />Fire Protection <br />Commercial exempt for <br />Other: <br />Estimated date well constructed ; Estimated date pump installed <br />Estimated date of first use ; Estimated flow rate gpm <br />How many other wells are located on this parcel? ; Uses: <br />Permit/Case Nos.: <br />Existing Well Owner Signature: Date: <br />For Office Use Only <br />Has information above been verified? If not, please note accordingly. <br />List any problems you have identified: (if none, please state so) <br />Date of inspection: Phone Number <br />Inspected by (print): (signed): <br />Attach photo(s) if available or needed for further evaluation. Additional comments or information on back. <br />