HomeMy WebLinkAboutWell Permit InformationForm No.
GWS-25
APPLICANT
(303) 866-3581
OFFICE OF THE STATE ENGINEER
COLORADO DIVISION OF WATER RESOURCES
etA-Centennial Bldg.;1313 Sherman St., Denver, Colorado 80203
RANCHO TRIO-EL JEBEL LLC
C/O PATRICK MILLER & KROPF PC
730 E DURANT AVE STE 2OO
ASPEN, CO 81611-
(970) e20-1028
APPROVED WELL LOCATTON
GARFIELD COUNTYNW 114 SW 114 Section 33
Township 7 S Range 87 W Sixth P.M.
ptsTANcEs FROM SECTTON LTNES
3125 Ft. from North Section Line
726 Ft. from West Section Line
UTM COORDINATES (Meters,Zone:1 3.NAD83)
Easting: Northing:
WELL PERN'T NUII'IBER
DIV.5 WD38
67194 -F_-_
DES. BASIN MD
ISSUANCE OF THIS PERMIT DOES NOT CONFER A WATER RIGHT
coNDliloNs oF APPROVAL
1) This well shall be used in such a way as to cause no material injury to exisling water rights. The issuance of this permit
does nol ensure that no injury will occur lo another vested waler right or preclude another owner of a vested water right from
seeking relief in a civil court action.
Z) The construction of this well shall be in compliance with the Water Well Construction Rules 2 CCR 402-2, unless approval
of a varianco has been granted by the Stale Board of Examiners of Water Well Construclion and Pump lnstallation
Contractors in accordancewith Rule 18.
3) Approved pursuant to CRS 37-9G137{2) for the expansion of use of an existing well, conslructed under Permil No.
124670, appropriating ground water tributary to the Roaring Fork River, on the condition that the well shall be operated only
when the Basalt Waler Conservancy Districfs substitute water supply plan, approved by ihe State Engineer, is in effect and
when a water allolmenl coniract between the well owner and the Basalt Water Conservancy Distric{ for lhe release of
replacemenl water fom Ruedi Reservoir is in effecl, or under an approved plan for augmentation. BWCD contract #518.
4) The use of ground water from this well is limited to domestic use in two single-family dwellings, the inigation of not more
than 3 acres of lawn and gardens, and fire protection.
5) The pumping rale of this well shall not exceed 30 GPM.
6) The annual amount of ground waler to be appropriated shall not exceed 8.734 acre-feet.
7J The owner shall mark the well in a conspicuous place with well permit number(s), name ol the aquifer, and court case
number(s) as appropriate. The owner shall take necessary means and precautions to preserve these markings.
S) A totalizing flow meter must be installed on this well and maintained in good working order. Permanent records of all
diversions must be maintained by the well owner (recorded al least annually) and submitted lo the Division Engineer upon' request.
9) This well shall be located not more than 200 feel from lhe location specified on this permit.
10) This well shall be located at least 600 feet from any existing well, completed in lhe same aquifer, that is not owned by the
applicant, excluding those wells whose owners were notified pursuant lo CRS 37-9S137(2XbXlD(A). Nolice was sent to the
owners of permil no(s). 89047-4, 24S)00, 106141, 198015, 264621,46570-F, and 5't471-F and no response was received.
11) The issuance of this permit hereby cancels permit na. 12467O4W 42f fu8
Permit Expiration Date Extended to May 29, 2O1O
AOT 5-28-09
State
APPROVED
CJL
AMENDMENT TO WATER ALLOTMENT CONTRACT
BASALT WATER CONSERVANCY DISTRICT
Contract No. 51.8a
WHEREAS, the Basalt Water Conservancy District ("District") granted Water Allotment
ContractNo.5lS dated April L0,2007,to Ranch Trio- El]ebel, LLC for0.067 cubicfeetof water
per second frorn the Districfs direct flow rights and 6.8 acre feet of storage or other
augmentation water owned or controlled by the District to serve certain property located in
Garfield County, Colorado, which land is described on Exhibit A; and
WHEREAS, by Consent dated September 20,20J.6, the District approved assignment of
the Contract to Anna G. Edgerly (the "Applicanf); and
WHEREAS, the Applicant has requested that the Contractbe amended to decrease the
District's direct flow rights from 0.067 to 0.033 cubic feet of water per second and decrease the
volume of storage or other augmentation water allotted thereunder from 6.8 to 1..0 acre feet.
WHEREFORE, the Contract shall be and hereby is amended to provide that the
Applicant shall be entitled to receive and apply to beneficial use 0.033 cubic feet of water per
second from the Dishicfs direct flow rights and L.0 acre feet per year of storage or other
augmentation water owned or controlled by the District. Applicant shall restrict actual
diversions and consumptive use under this Contract to these amounts. The Conkact amount is
based on the water requirements table attached hereto as Exhibit B, which shall replace any and
all water use or allocation schedules previously associated with this contract. Any further
inctease or change in the water requirements to be served by the District will require an
amendment to the subject contract.
The Amendment is made subject to the following conditions:
1. Any and all conditions imposed upon the release and diversion of water aliotted
hereunder in any water rights plan of augmentation or other water rights decree of the Water
Court for Water Division No. 5, including Case No. AZCW77, shall be incorporated herein as a
condition of approval of this contract. Granting of this allotment contract does not constitute
the District's representation that the Applicant will receive a well permit or water rights d.ecree
for the land to be benefited hereby.
2. PAYMENT: Applicant shall pay annually for the water service described herein
at a price to be fixed annually by the Board of Directors of the Dishict for such service. Payment
of the annual fee shall be made, in full, within fifteen (15) days after the date of a notice from
the Dishict that the payment is due. Said notice will advise the Applicant, among other things,
of the water delivery year to which the payment shall apply and the price which is applicable to
that year. If a payment is not made by the due date, a late fee of $50 (or other amount as the
Board may set from time to time) will be assessed and final written notice of the delinquent
account and late fee assessment will be sent by the District to the Applicant at Applicanfs
address set forth in the Assignment attached. If payment is not made within thirty (30) days
1
after said final written notice, the District may, at its option, elect to terminate all of the
Applicant's right, title, or interest under this Contract, in which event the water right allotted.
hereunder may be transferred, leased or otherwise disposed of by the Dishict at the discretion
of its Board of Directors.
3. WELL PERMIT: If Applicant intends to divert through a well, then Applicant
must provide to District a copy of Applicanf s valid well permit before the District is obligated to
deliver any water hereunder, and it is the Applicanfs continuous duty to maintain a valid weli
permit. Applicant shall also comply with all restrictions and limitations set forth in the well
permit obtained from the Colorado Division of Water Resources. Applicant must comply with
the well-spacing requirements set forth in C.R.S. S 37-90-137, as amended, if applicable.
Compliance with said statutory well-spacing criteria shall be an express condition of the
extension of service hereunder, and the District shall in no way be liable for an Applicanfs
failure to comply. Applicant agrees to mark the well in a conspicuous place with the permit
number.
4. MEASURING PEVICE OR METER: Applicant agrees to provide, at its own
expense/ a totalizing flowmeter withremote readoutto continuously and accurately measure at
all times all water diverted pursuant to the terms of Applican/s water right and the terms of
this Contract. On or before November 15 of each year, Applicant will provide accurate readings
from such device or meter (recorded on a monthly basis for the period November 1. through
October 3L of each year) to District, the Division Engineer and Water Commissioner. Applicant
acknowledges that failure to comply with this paragraph could result in legal action to
terminate Applican(s diversion of water by the State of Colorado Division of Water Resources.
By signing this Conhact, Applicant hereby specifically allows District, through its authorized
agent to enter upon Applican/s property during ordinary business hours for the purposes of
determining Applicanf s actual use of water.
5. C9MPLIANCE WITH SECTION 404 OF THE CLEAN WATER &CT. Applicant
shall comply with Section 404 of the Clean Water Act and consult with the Army Corps of
Engineers to complete any Section 404 compliance that may be required as a result of the
construction of any facilities necessary to use contract water.
6. CONTRACT TERMINATION:
A. Blr District:
1,. The District may terminate this Contract for any violation or
breach of the terms of this Contract by Applicant, or Applicanfs breach of
any other contract with the District.
2, The District may terminate this Contract if, in its discretion, any
judicial or administrative proceedings initiated by Applicant threaten the
District's authority to contract for delivery or use of the District's water
rights, or threaten the District's permits, water rights, or other interests of
the District.
1
Except as herein expressly amended and modified, said Water Ailotment Contract shall
be and remain in full force and effect.
srfl'r
Dated this#;{- day of:}um,2029.
B. By Applicant:
1. Applicant may terminate this Conh'act in its entirety for any
reason by notifying the District in writing of the termination on or before
April 1. Notice by said date will prevent the Applicanfs liability for the
next annual contract charge.
Anna G. Edgerly
STATE OF COLORADO
EagL
)
)ss
)COUNTY OF
f+Ad"Ihe above and f<rregoing docurnent was acknowledged before me this
of |nne,2123,by Anna G. Edgerly.
Witness my hand and official seal.
My commission expires: 62/tt / 2{,
Public
1'?*r day
LOUIS CTftDIE LiFAY GUIfiTO
f{OTARf FUSTIC . STATE OF COLORAOO
NoTaRY rD ?0?14006003
i6Y C0fir,1155i0$ EXPIR€S FES 1 1' 10?6
3
The foregoing Amendment to Water Allotment Contract is approved by the Board of
Directors of the BasaltWater Conservancy District on this 20th day of June X)23.
BASALT WATER CONSERVANCY DISTRICT
Name:
Attest:
Kennedy,
Secretary to the Meeting
By:
4
EXHIBIT A
Legal Description
A tract of land in U.S. Government lots 7 & 8 in Section 33, Township 7 South, Range 87 West of
the 60' Principal Meridian described as beginning at a point in the southerly right-Jf-way fence
line of Colorado State Highway No. 82 from whence the SE corner of said Section 33 bears S 64.
11' 0y'E. a distance ot5351,.797 feel thence 572" A9'58" E. a distance of 'j.M.829 feet along said
southerly right-of-way fence line of Colorado State Highway No. 82; thence S 0L" 15' 00,, W. a
distance of 1,446.2'l'5 feet to the south line of U.S. Government lot 8; thence S 89'08'00" W a
distance of 138.90 feet along the south line of said U.S. Government lot 8; thence N. 01"Lf 00" E.
a distance of 1492.682feet to the point of beginning.
County of Garfield
State of Colorado
5
BASALT W,CTER CONSERVANCY OISTRICT
WATER REQUIREMENTS
(acre feet)
Contract 518 Arxendment
{14)
Source of
Ain/Renlace
GNM
GNM
GNM
GNM
GNM
GNM
GNM
GNM
GNM
GNM
GNM
(1 3)-
Delayed
Depletions
0.025
0.026
0.031
0.051
0.063
U.UbJ
0.052
0.046
0.032
0.026
0.464
(7)(8)
Pond
Evan
(e)
Lawn
lffidation
{1 0)
Crop
lrrisation
(1 1)
Livestock
i12)-
TOTAL
Domestic
ln-houqe
0.017
0.016
0.019
fl nto
0.064
0.076
0"074
0.054
0.049
0.029
0.018
0.017
0.464
U.UUU
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
Assumptions
of Livestoc*.11
% CU for Domstic/Commercial 15
% Lavn lrrig. Efficiency
Consumption of lilig. (aflac)
dU
2.009
7o Crop lrnE. Etfioency
Consumption of lnig. (afiac)
6U
0.000
Elevatian (i€et)6390
0.00u
0.000
0.000
0.000
0.o0cl
0.000
0.000
0.000
0.000
0.000
0.000
0 000
0.0i}0
0"000
0.000
0.007
0.046
0.044
U,UIO
0.024
0.008
0.000
0.000
0.'t91
0.002
0.002
0.0il4
0.006
0.008
0.009
0.010
0.009
0.006
0.005
0.003
tl 602
0.065
0.014
o.412
0.014
0.013
0.014
0.013
0.014
0.014
0.013
0.014
c.013
n o'1.4
u- ioz
(5)
t7)
/a\
{10}
(e- 1 uJ
(1)
Domestic
ln-house
{21
Pond
eva!.
Lawn
lnioation
(4i (5) {6}
Crop
lrriaation Liveslock TOTAL
0,093
0.085
0.095
0.1 03
0.1 45
0.1 55
0.1 55
0.1 33
0.125
0.1 06
0.091
0.093
1.382
NUMSER OF RESIDENCES jlE
100
# persons/residence
f oallons/n,orsonl.fav
Cornmer$all0ther Demand (af)0.00Cr Office
Sq. Ft. of Lawn lrrigated
La\tun Application Rate (afJac)
4,1 50
2.51i
Acres ot l;rop lrngated
Croo Aoolication Rate {af/ac)
U.UU
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
U.UUU
0_000
0.000
0.000
0.00t]
0.080
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.00s
0.000
0.000
0.008
0.046
0.057
0.055
0.033
0.030
0.010
0.000
0.000
0.239
0.002
0.002
0.004
0.006
0.008
n nno
0.010
0.009
0.006
0"005
0.003
0"002
n nA6
U"U9?
0.083
0"092
0.089
n nq,
0.083
c.092
0.092
0.08s
0.092
0.089
0.092
1.078
(1)
(2)
(3)
(A)
Month
January
February
March
Aprl
May
June
July
August
September
October
November
FJecember
TOTALS ->
A4
AWell
from Ditch
Fork River
100/o from Green Mfir.
X
r&
Ed
-l
w
Form No.
Gt /s44
stn24
Page
1of 3
STATE OF COLORADO
OFFICE OF THE STATE ENGINEER
1313 Sherman St., Room 821, Denver, CO 80203
Phone : (303) 866-3581 Website : h *os: i/dwr.eelqrado.g-av/
Email to: dwroermitsonline@state. co.us
Ofiice Use Only
RESIDENTIAL Water Well Permit Application
Note: Also use this form to apply for livestock waterlng
Reviewform lnstructlons orior to completinq form.
1. Applicant lnformation 6. Use Of Well (check applicable boxes)
Anna
17527 Highway 82
See instructions b determine use(s) forwhich you may qualif
ilA. Ordinary household use in one single-family dwelling
(no outside use)
Etr B. Ordinary household use in 1 to 3 single-iamily dwellings:
Number of dwellings:2
il Home garden/lawn irrigation, not to exceed one acre:
area irigated fisq.ft.Clacre
fi Domestic animal and poultry watering (non-commercial)
F C. Livestock watering (on farm/ranch/nnge/pasture)
City
Carbondale
State I Zp Code
lerczeco
Telephone # (area code & number)
9702742442
E-mail (online filing required)
2 of le boxes
Construct new w€ll Change source (aquifer)
ffi Replace existing lvell
ffi Use existing well
Hl change or increase use
il Reapplication (expired permit)
il Rooftop precipitation collec{ion
il other:
3. Refer To (if applicablel 7. Well Data (proposedl
vvell permf #
518a
\lffier Court case #Maximum pumping rate
GPM
Annual amount to be withdrawn
1 acre-feet
Designated Basin Determination #\ bll name or #Total Depth Aquiier
4. Location Of Proposed Well (SEE INSTRUCTIONS)8. Water Suoolier
Propedy address {lnclude City, State, Zip) !!l Check if well address is same a$ ltem 1 ls ihis parcel within boundaries of a water service area? SvEs E ruO
lf ves. orovide name of suoolier: Basalt \A/ater Conservancv
Rule 6.2.3 ff Yes E No
(see instruction for information)
County 9. Type Of Sewage System
E Septic tank / absorption leach field
ffiCentral system: Distric{ name
HVauh: Location ser/age to be hauled to:-
fiother /exolain)
'll4 of the 1t4
sectron Township N or Sna I
Ranse F orW
l'"
Preferred location format: GPS well location information in UTM format. The
lollowing GPS settings are required: Format must b€ UTM. Units musl be in
meters" Datum must be NAD83. Unit must be set to true north.
ff zone 12 orffZone 13.
Easting:
Northing:
10. Proposed Well Driller License # (optional):
11. Sign or Enter Name of Applicant(s) orAuthorized Agent
The making of false statements herein constitutes perjury in the seond
degree, trv*rich is punishable as a class 1 misdemeanor pursuant to
C.R,S- 24-4-104 (13Xa). I have read the statements herein, know the
contents thereof and state that they are true to nry knowledge.
Optional Location lnformation (must be provided if GPS location is not
provided above and Rule 6.2.3 does not apply): distances from section lines
feetfromthe[f N. or[lS. Line,
feet from the [l E. orflw. Line
Sign or enter name(s) of peGon(s) submitting application
Anna G Edgerly
Date (mm/ddtwyy)
12t23t2024
5. Parcel On Which Well Will Be Located
fYou must aftach a current deed for the subiect oarcel)
lf signing print name
Anna Edgerlymustcomplete one of the following:
il subdivision: Name
Lot Block_ Filing/Unit
E County exenption (attach copy of county approval & survey)
Namel#- Lot
fr$ Parcel less than 35 acres, noi in a suMivision attach a deed with metes
& bounds description recorded prior to June 1,1972, and current deed
fi tvtining claim (atiach copy of deed or survey) Namel#:
ffi Square 40 acre parcel as described in ltem 4 (1/4 ofthe 114 is required)
il parcet of 35 or more acres (aftach nretes & bounds description or survey)
ffother:metes & bounds or
acres you owner of this parcel? lf no, list owner.
Elvss ffr'ro
Title
Owner
Office Use Only
D. Wll this be the only q/ell on this parcel?filYEs UNo (if no - list other wells)
E. Parc€l lD# (optional):
COLORADO DIVISION OF WATER RESOURCES GWS.44 RESINST (512024)
DEPARTMENT OF NATURAL RESOURCES
RESIDENTIAL WELL PERMIT APPLICATION INSTRUCTIONS (Page 2 of 3)
The form must be typed or printed in DARK lNK. A current deed for the subiect parcel must be attached. All changes on the
form must be initialed and dated. Attach additional sheets if more space is required. INCOMPLETE, POOR QUALITY' OR
ILLEGIBLE FORMS CANNOT BE PROCESSED AND WILL BE RETURNED. Applications are evaluated in chronological
order. Please allow approximately seven weeks for processing.
To submit the application you will need to save the completed PDF form and email the PDF to:
dwrpermjtsqnline@state.to.us.Once the email is received you will receive an email, in addition to the response, with an aftached
invoice containing a link to submit payment online via eCheck or credit/debit card. Refer to the 'Form Submittal, Payment Options
and Fee Schedule" instructions, found under"lmportant Links" on the Well Permitting page (httpqf,/chvl.coleGgLo.govlsegleeslwell:
permittilg) for further information. Once the PDF form has been submitted you will receive an email with an attached invoice
containing a link to submit payment online, This form will not be processed until the fee has been received. Fees are
nonrefundable.
EES,: The filing fee forthis application is $100. Exceptions are as follows:
1. An application to replace or deepen an existing permitted well, which does not have a "-F" or "-R' suffix after the original
permit number, into the same source (aquifer) for the same uses is $60.
2. Applications to register an existing well and replace or deepen the well into the same source (aquifer) for the same uses is
$100 if submitted toqether. Use Form GWS-12 for the registration and Form GWS-44 for the replacement. lf the intent is
only to register an existing well use Form GWS-12. The forms are available from the eFffis Daehbgard.
USES: This form (cWS-44) is to be used when applying for a permit for the following types of uses:
A. Ordinary household use inside one single-family dwelling (NO outside water use allowed): Generally, this is allthat
can be approved on parcels less than 35 acres, except in areas inside the Qe-qtq-nAted Segins, limited areas on the Western
Slope where the stream system is not overappropriated, for subdivisions under a court approved plan for augmentation that
allow outside uses' and for wells constructed into certain DenvetBagn aquifers'
B. Ordinary household use in I to 3 single-family dwellings, irrigation of up to one acre of home garden and lawn, and
watering of domestic animals and poultry: Generally, permits can be approved with residential outside uses in addition
to use inside the single family dwelling(s) on parcels of land of 35 or more acres, in areas inside the Designateel Basins,
limited areas on the Western Slope where the stream system is not overappropriated, for subdivisions under a court approved
plan for augmentation that allow outside uses, and for wells constructed into certain Denver€asin aquifers. The allowed
residential uses will vary based on the property size, property location and the proposed aquifer.
c. Livestock watering on farm, ranch, range, or pasture (on parcels of 35 or more acres).
ITEM INSTRUCTIONS: {numbers correspond with those on the front of this form)
1. (Applicant lnformation) The applicant is the entity for whom the permit is to be issued. Since the well owner is ultimately
responsible for the use of the well, their name should be in this area. The mailing address is where the applicant cunently
receives mail. For wells in a Denver Basin aquifer the Applicant must be the property owner.
2. (Type of Application) Check all boxes that apply. lf you check the box for Rooftop precipitation collection, you must
also complete and submit Form No. GWS-78. The form is available from the eForms board
3. (Refer To) Complete all boxes that apply.
4. (Location of Proposed Well) Provide the property address for the parcel on which the well is to be located. lf it is the same
as the mailing address, check the box that indicates that it is the same. You mugt prwlde the munty, %dtET+,s€r#ion,
hynahip, nangs and prindpal metidian (P.M.) in which the well will be located. You must also provide a point location unless
the well qualifies under Rule 6.2.3 of the Water Well Construction Rules (Rule 6,2.3 requires that the point location be
provided to the Division of Water Resources by the well driller once the well is drilled). Rule 6.2.3 does not apply in the
following circumstances:
a. The location is decreed by a water court,
b. The well will be drilled in a Denver Basin aquifer;
c. Your application is for a permit to use an existing well.
When a point location is required it is recommended the well location be provided using GPS coordinates. The Location
Converter tool (available on the DWR website at: https:{dwr.sJale.cq-usiToolsllqcatignQQnvedq) can be used to convert
between Latitude/Longitude and UTM coordinates. lf a UTM format location is not provided and the well does not qualify
under Rule 6.2.3 you must provide the distances from section lines. The required GPS unit settings must be as indicated on
this form. Colorado contains two UTM zones. Zone 13 covers most of Colorado. The boundary between Zone 12 and Zone
13 is the 108th Meridian (longitude). West of the 108th Meridian is UTM Zone 12 and east of the 'l08th Meridian is UTM
Zone 13" The 108th Meridian is approximately 57 miles east of the Colorado-Utah state line. On most GPS units, the UTM
zoneisgivenaspartof theEastingmeasurement, e.g. 12T01 23456. Checktheappropriatebox. Whenapointlocation
is required, and GPS coordinates are not provided, you must specify the Distances of the well from the Section
lines.
COLORADO DIVISION OF WATER RESOURCES
DEPARTMENT OF NATURAL RESOURCES
GWS-44 RESTNST {5AO24)
RESIDENTIAL WELL PERMIT APPLICATION INSTRUCTIONS (Page 3 of 3)
5. (Parcel on Which Well Will Be Located) A currqnt deed for the subiect oarcel must be attached. lf the subject parcel
is 35 or more acres, a complete metes and bounds type legal description or surveyor's plat map that references a section
point is required to enable us to plot the parcel in our mapping system. lf the parcel is less than 35 acres and not in a
subdivision, a deed with metes and bounds legal description, recorded priorto June 1, 1972is required. Complete ltems
5A through 5E (5E is optional). lf you answered NO to ltem 5C please indicate who the landowner is. lf you are under a
contractto purchase the subject property, please state this as well. lf the parcel is inside the Denver Basin, the application
must be in the name of and signed by, or their name entered by, the current landowner.
6. {Use of Well} See above comments under USES to determine those uses for which you may qualify, and then check the
applicable box or boxes.
7. (Well Data) The maximum pumping rate is limited to 15 gpm for most residential type well permits. The annual amount
of water to be withdrawn is a volume measured in acre-feet. One acre-foot equals 325,851 gallons. For ordinary household
use inside one single-family dwelling and no outside use, the annual amount will be about 1/3 acre-foot. For ordinary
household use in three single-family dwellings, one acre of home garden/ lawn irrigation, and watering of domestic animals,
the annual amount will be about 3 acre-feet. For 100 head of livestock, the annual amount will be about 1.35 acre-feet.
Please indicate the estimated depth of the proposed well. The proposed aquifer for the well must be indicated if the well is
to be located within the DelvelBegi! (see Denvel E-aglLAAap-), the San Luis Valley or in areas where it is believed the well
will penetrate a eonfining layer. Aquifer information should be provided if known, for well locations outside of these areas.
8. The issuance of exempt well permits may depend on the availability of another source of water, pursuant to CRS 37 -92-
602(6), such as water from a municipality or water district. (Statutes can be accessed through the CDWR web site.) See
eldej1ne 2003-5 for additional information.
9. Check the applicable box, and complete or attach any additional information as requested in this item.
10. Wells must be constructed by a Colorado licensed well driller, or under the "private driller" provision as defined in CRS 37-
91-1O2(12J. A listing of licensed well drillers/pump installers is available at hftps:l&lwl.colorado.qovGggbgsl'vvell
c a n stru cJio n:Ln g p ecti qa
11. The well owner must sign or entertheir name on the form in the signature block. lf signing as a representative of a
company who owns the well, then your title must also be included in the title block. An authorized agent may also sign or
enter their name on the application if a letter signed by the applicant or their attorney is submitted with the application
authorizing that agent to sign or enter their name on the applicant's behalf. Put the date the application was signed (or name
entered) in the date block. Wet or electronic signatures are acceptable. lf providing a wet signature type or print the name
in the print name block.
lf you have questions, contact the Denver Office or the Division Office where the well is located or submit a question at: Asl<DlVB
- Residentra.lWe[ for assistance. Contact information is availabb from our website at: httpg:lldwr.qqlotado.qov/abqut-ug:conlaat:
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