General Purpose Water Well Permit Application
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1
2COLORADO DIVISION OF WATER RESOURCES
Office Use Only
Form GWS-45 (07/2013)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST, RM 821, DENVER, CO 80203
Main: (303) 866-3581 Fax: (303) 866-2223
dwrpermitsonline@state.co.us
GENERAL PURPOSE
Water Well Permit Application
Review instructions on reverse side prior to completing form.
The form must be computer generated, typed or in black or blue ink.
1. Applicant Information
6. Use Of Well (check applicable boxes)
Name of applicant
Attach a detailed description of uses applied for.
Industrial
Dewatering System
Mailing address
Municipal
Geothermal (production or reinjection
Irrigation
Other (describe): ______________________
City
State
Zip code
Commercial
7. Well Data (proposed)
Telephone # (area code & number)
E-mail (online filing required)
Maximum pumping rate
Annual amount to be withdrawn
gpm
2. Type Of Application (check applicable boxes)
acre-feet
Total depth
Aquifer
Construct new well
Use existing well
Replace existing well
Change or increase use
feet
Change source (aquifer)
Reapplication (expired permit)
8. Land On Which Ground Water Will Be Used
COGCC Well
Other: ________________
Legal Description of Land
(may be provided as an attachment):
3. Refer To (if applicable)
Well permit #
Water Court case #
Designated Basin Determination #
Well name or #
4. Location Of Proposed Well
County
(If used for crop irrigation, attach a scaled map that shows irrigated area.)
1/4
A.
B.
1/4 of the
# Acres
Owner
Section
Township
N or S
Range
E or W
Principal Meridian
C.
List any other wells or water rights used on this land:
Distance of well from section lines (section lines are typically not property lines)
N
S
E
W
Ft. from
Ft. from
9. Proposed Well Driller License #(optional):
For replacement wells only – distance and direction from old well to new well
10.
Sign or Entered Name Of Applicant(s) Or Authorized Agent
feet
direction
The making of false statements herein constitutes perjury in the second
Well location address (Include City, State, Zip)
Check if well address is same as in Item 1.
degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S.
24-4-104 (13)(a). I have read the statements herein, know the contents
thereof and state that they are true to my knowledge.
Sign or enter name(s) of person(s) submitting application
Date (mm/dd/yyyy)
Optional: GPS well location information in UTM format You must check GPS unit for
required settings as follows:
Format must be UTM
If signing print name and title
Zone 12 or
Zone 13
Easting
Units must be Meters
Datum must be NAD83
Office Use Only
Northing
Unit must be set to true north
USGS map name
DWR map no.
Surface elev.
Was GPS unit checked for above?
YES
Remember to set Datum to NAD83
5. Parcel On Which Well Will Be Located
Receipt area only
(PLEASE ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL)
A.
Legal Description
(may be provided as an attachment):
AQUAMAP
B.
C.
# of acres in parcel
Owner
WE
WR
D.
Will this be the only well on this parcel?
YES
NO (if no list other wells)
CWCB
TOPO
E.
MYLAR
State Parcel ID# (optional):
DIV _____ WD _____ BA _____ MD _____
SB5
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