DWR_2673735

• Permitno: 295950
• Receipt Number: 3666607
• Document Type - Well Permit: Original File
• Annotated?: No

Form
COLORADO DIVISION OF WATER RESOURCES
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No.
DEPARTMENT' OF NATURAL RESOURCES
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GWS-
1313 SHERMAN ST., Ste 821, DENVER, CO 80203
RECEIVED
12 -A
10/2011
Phone: [phone] Fax: [phone]
SEP 1 6 2014
RESOURCE S SEP 1 i Z014
TATE ENGINEER
STATEMENT OF HISTORICAL USE WATER
Review form Instructions prior to completing form
COLO gvIgIONEWMER
This form Is to be submitted with the Registration form, GWS -12
KOLO,COLORPfl0
I, I Y, do state as follows: I am the owner of a well located in the
(prim name of well owner
D1 /4 of the 1/4, Sec, Township � ❑ N. or U S., Range (10b D E. or [AW , Lj�_ P.M.
Water Court case no. (if appglicable), Owners we(I esignation ( II name)
`�
Location of well (street address - if applicable)- 3 1 K / h 0 / I Yl r G Lvl .. p
Location of well (subdivision name/lot/block/filing — if applicable): ali —30 � d ✓ i3i � � 1 S ale
%m do _ /
Is historicWl use on same parcel as where well is located? _ Yes/_ No. If no, provide location where well is used
( address/subdivsion nameAoMock/fihng):
Size of parcel where well is located , b acres. Will this be the only Well on the parcel? Yes/ _ No. If no, list permit number(s)
or water court decree case number(s) for other well(s)
Will future use be on same parcel as historical? Yes! _ No. If no, provide new location (address/subdivision name /lot/block/filing)
Existina well location and visual c nti for s: If stating no, must include an explanation of the circumstances.
Type of existing well (circle one): drilled; and dug pring well, allery well; gravel pit; other
Distance to nearest septic tank/sewer line (approximate) feet Distance to nearest leach field (approx.) ]VIA feet.
Is the well in a dean and sanitary location?
Is the ground at the surface surrounding the vAll firm and stable and sloped away from the well for proper drainage? /V 114
Is the well situated in a well house or vault? _�/ $S If so, is the well house or vault in good repair and condition? V P S
Existing well construction and materials: If stating no, must include an explanation of the circumstances.
Is the well equipped with a sanitary well seal /caps
Is the well constructed with steel casing that extends at least one (1) foot above the ground surface?
Casing size (diameter) inches.
Who constructed well? W n l° r Who installed pump? n U) Y12(�
Historical use initiated Prior to May 8. 1972
The well identified above has been used since prior to May 8, 1972 as the water supply for the following exempt uses listed in § 37- 92.602,
C.R.S. (or § 37 -90 -105, C.R.S., in a Designated Ground Water Basin):
a) Ordinary household use inside single- family dwelling(s) (maximum of 3 single family dwellings);
b) The irrigation of 0 acre /square feet (circle one) of home gardens and lawns (maximum of one acre - one
acre is equivalent to 43,560 square feet);
c) The watering of domestic animals/poultry yesL�no; livestock on a farm or ranch yes/ -A:�,Ino
OR (above uses cannot be combined with commercial uses)
d) Drinking and sanitary facilities inside an individual commercial business_ yes/ no (If commercial use claimed, Form
GWS -57, Commercial drinking and sanitary well worksheet, must also be completed nd submitted.)
(Note: Commercial wells in a Designated Ground Water Basin may also include outside uses )
Have the above claimed uses been in continuous use since May 8, 1972? XYes/ _No If no, for each claimed use, list dates when
this well supplied the above daimed uses:
I understand that uses that were not initiated prior to May 8, 1972 are not eligible for registration and any expansion of use that occurred
after May 8, 1972 is not eligible for registration. Additionally, I understand that if the well has not been operational or has not existed for a
period of at least ten 1 not elfaible for reuistration.
The making of false statements herein constitutes perjury in the second degree, which is punishable as a class 1 misdemeanor pursuant
to § 23- 3- 104(13)(a), C R.S I have read the statements herein, know the contents thereof, and state they are true to my knowledge.
Print Name & Title (Well Owner(s))
Signature of Well Owner(s)
Date