HomeMy WebLinkAboutWell PermitForm No. STATE OF COLORADO
GWS-44 OFFICE OF THE STATE ENGINEER
5/2024 1313 Sherman St., Room 821, Denver, CO 80203
Page Phone: (303) 866-3581 Website:htt s://dwr.colorado. ovI
1 of 3 Email to: dwr ermitsoniine state.co.us
RESIDENTIAL Water Well Permit Application
Note: Also use this form to apply for livestock watering
Review form instructions prior to completing form.
Office Use Only
1. Applicant Information
6. Use Of Well (check applicable boxes)
Name ofApplicant(s)
See instructions to determine use(s) for which you may qualify
Ryobi Foundation
❑ A. Ordinary household use in one single-family dwelling
(no outside use)
Mailing address
13114 Highway 82
❑x B. Ordinary household use in 1 to 3 single-family dwellings:
city
State
Zip code
Carbondale,
CO
181623
Number of dwellings: 2
Telephone # (area code & number)
E-mail (online filing required)
919-619-3295
bobbi@ryobifoundation.org
0 Home garden/lawn irrigation, not to exceed one acre:
area irrigated 1 ❑ sq. ft. 0 acre
2. Type Of Application (check applicable boxes)
0 Construct new well
❑ Change source (aquifer)
❑ Replace existing well
❑ Reapplication (expired permit)
0 Domestic animal and poultry watering (non-commercial)
❑ Use existing well
❑ Rooftop precipitation collection
❑ C. Livestock watering (on farm/ranch/range/pasture)
❑ Change or increase use
❑ Other:
3. Refer To (if applicable)
7. Well Data (proposed)
Well permit #
Water Court case #
Maximum pumping rate
Annual amount to be withdrawn
15 GPM
3 acre-feet
Designated Basin Determination #
name or #
4. Location Of Proposed Well SEE INSTRUCTIONS
Property address (Include City, State, Zip) U Check if well address is same as Item 1
Rule 6.2.3 0 Yes ❑ No county
(see instruction for information) Garfield
Section Township N or S Range E or W P.M.
SE 1/4 of the NE 1/4 26 7 ❑ ❑x 88 ❑ 0 6th
Preferred location format: GPS well location information in UTM format. The
following GPS settings are required: Format must be UTM. Units must be in
meters. Datum must be NAD83. Unit must beset to true north.
❑ Zone 12 or ❑ Zone 13.
Easting:
Northing:
Optional Location Information (must be provided if GPS location is not
provided above and Rule 6.2.3 does not apply): distances from section lines:
feet from the ❑ N. or ❑ S. Line,
feet from the ❑ E. or ❑ W. Line
5. Parcel On Which Well Will Be Located
(You must attach a current deed for the subject parcel)
A. You must check and complete one of the following:
❑ Subdivision: Name
Lot Block Filing/Unit
❑ County exemption (attach copy of county approval & survey)
Name/# Lot #
❑ Parcel less than 35 acres, not in a subdivision attach a deed with metes
& bounds description recorded prior to June 1, 1972, and current deed
❑ Mining claim (attach copy of deed or survey) Name/#:
❑ Square 40 acre parcel as described in Item 4 (1/4 of the 1/4 is required)
❑ Parcel of 35 or more acres (attach metes & bounds description or survey)
0 Other: (attach metes & bounds description or survey)
B. # of acres in parcel C. Are you the owner of this parcel? If no, list owner
41.67 0 YES ❑ NO
D. Will this be the only well on this parcel?[0YES ONO (if no —list other wells)
Total Depth I Aquifer
upto 400 feet E Tributary
8. Water Supplier
Is this parcel within boundaries of a water service area? OYES 0 NO
If yes. provide name of supplier:
9. Type Of Sewage System
0 Septic tank / absorption leach field
❑ Central system: District name
❑ Vault: Location sewage to be hauled to:
❑ Other (explain)
10. Proposed Well Driller License # (optional): 1095
11. Sign or Enter Name of Applicant(s) or Authorized Agent
The making of false statements herein constitutes perjury in the second
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 %.gnter game(s) of pefson(s) submilting application I Date (rnrnmdryyyy)
If sicjhing print name
Barbara Hapgood
Title
CEO/President
Office Use Only
10/9/2025
E. Parcel ID# (optional):
2393-234-03-005