Fill and Sign the It is the Applicants Responsibility to Provide the Location for Each Structure in This Application Form

JDF 298W(a) R5-15 APPLICATION FOR UNDERGROUND WATER RIGHT AND CERTIFICATE OF NOTICE Page 1 of 6© 2013, 2014, 2015 Colorado Judicial Department for use in the Courts of ColoradoDistrict Court, Water Division ___________________, Colorado Court Address:________________________________________________________ CONCERNING THE APPLICATION FOR WATER RIGHTS OFApplicant:In the ____________________________River or its TributariesIn ________________________________________ COUNTY COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E-mail:FAX Number: Atty. Reg. #:Case Number:Division: Courtroom:APPLICATION FOR  CONDITIONAL  ABSOLUTE UNDERGROUND WATER RIGHTIt is the applicant’s responsibility to provide the location for each structure in this application. For structures that are already decreed, use the location from the most recent decree that adjudicated the location. UTM coordinates (for example from a GPS device), or measured distances in the field from known section lines are acceptable. The Division Engineer, the Water Referee, or the Water Judge, may order the applicant to confirm the location of any structure with UTM coordinates, a survey, or other method.If Applicant is applying for an underground water right for an exempt well pursuant to § 37-92-602(4), C.R.S. or an underground water right in the Denver Basin Aquifers, Applicant should use Form JDF 298Wb or JDF 308W, respectively.1. Name, mailing address, email address, and telephone number of applicant(s) (if there are multiple applicants, and the space provided is not adequate to list all of the applicants, the names, addresses, telephone numbers and available email addresses must be provided as an attachment):Name of ApplicantMailing AddressEmail addressTelephone Number2.Name(s) of well(s) and permit, registration, or denial number(s). Attach copies of well permit, pump installation report, well construction and test report and statement of beneficial use (if available). (If permit applied for, but not acted upon, give date of permit application.)Name of WellPermit, Registration, or Denial NumberIf Permit is pending, check box below and provide date of application. Date: Date: JDF 298W(a) R5-15 APPLICATION FOR UNDERGROUND WATER RIGHT AND CERTIFICATE OF NOTICE Page 2 of 6© 2013, 2014, 2015 Colorado Judicial Department for use in the Courts of Colorado3. Legal description of well: Location information in UTM format (Preferred):UTM Zone must be 12 or 13; Units must be Meters; Datum must be NAD83; and Units must be set to true North. Include the source of the UTM coordinates, for example: GPS device; a GIS System such as DWR AquaMap or CDSS MapViewer; scaled from USGS topographic map; or other source. In areas having generally recognized street addresses, also include street address, and if applicable, the lot, block, and subdivision. Attach a legible 8 ½ x 11 inch map to this application illustrating location of the well.UTM coordinatesEasting ___________________ Northing _____________________Zone 12 Zone 13Street Address:_______________________________________________________________________Subdivision:LotBlockSource of UTMs (for example, hand-held Garmin GPS): Accuracy of location displayed on GPS device (for example, accurate to within 200 feet):Legal Description Using the Public Land Survey System (PLSS) (Optional; Please include both UTM and PLSS descriptions if known): Include perpendicular distances from section lines, and indicate ¼ ¼, section number, township, range, meridian and county; mark the location of the well on a USGS topographic map and attach to this application a legible 8 ½ x 11 inch copy of the applicable portion of the map. In areas where section lines have not been established, a bearing and distance to an established government monument is acceptable. Include the source of PLSS information, for example: GIS System such as DWR AquaMap or CDSS MapViewer; field survey; scaled from a USGS topographic map; or other source. In areas having generally recognized street addresses, also include street address, and if applicable, the lot, block, and subdivision.Legal Description: County______1/4 of the _____1/4 SectionTownship_______N or S Range_______E or WPrincipal MeridianDistance from section lines (not from property lines) ____________ Feet from N S and _____________ Feet from E  WSource of PLSS information: __________________________________________________________Street Address:_______________________________________________________________________Subdivision:LotBlock4.A. Source of water (for example, groundwater tributary to the South Platte): B.Depth of well, if completed: JDF 298W(a) R5-15 APPLICATION FOR UNDERGROUND WATER RIGHT AND CERTIFICATE OF NOTICE Page 3 of 6© 2013, 2014, 2015 Colorado Judicial Department for use in the Courts of Colorado5. A. Date of appropriation: ____ B. How appropriation was initiated: C.Date water applied to beneficial use (for example, the date that the applicant first operated the well for its intended use): 6. Does the well withdraw tributary groundwater: Yes No If YES fill out A and B:A.Amount claimed in gallons per minute (gpm) or cubic feet per second (cfs): Conditional _____________ ( gpm  cfs)Absolute _______________ ( gpm  cfs)B. Amount claimed in acre feet annually (one acre foot is the amount of water required to cover an area of one acre to a depth of one foot, and is equal to approximately 325,900 gallons)Conditional _____________ (acre feet)Absolute _______________(acre feet)If claiming an absolute water right, application shall include supporting evidence that applicant diverted water in-priority and applied such water to the beneficial uses claimed in the amounts claimed.7.Does the well withdraw nontributary groundwater:Yes No If YES fill out A, B, and C:A.Name of aquifer into which the well is drilled, if known: B.Amount claimed in gpm or cfs: Conditional _____________ ( gpm  cfs)Absolute _______________ ( gpm  cfs)C. Amount claimed in acre feet annually (one acre foot is the amount of water required to cover an area of one acre to a depth of one foot, and is equal to approximately 325,900 gallons)Conditional _____________ (acre feet)Absolute _______________(acre feet)If claiming an absolute water right, application shall include supporting evidence that applicant diverted water and applied such water to the beneficial uses claimed in the amounts claimed.8. Does the well operate pursuant to a decreed plan for augmentation? Yes No If YES fill out A and B:A.Case number of plan for augmentation: B. Is plan for augmentation operational? Yes No9.List All Uses or Proposed Uses A.If irrigation, complete the following:Number of acres historically irrigated _____________; proposed to be irrigated ___________________. Does the Applicant intend to use this water right to supplement irrigation on an area of land already irrigated under another water right?  yes  noLegal description of irrigated acreage. Mark the location of the irrigated acreage on a USGS topographic map and attach to this application a legible 8 ½ x 11 inch copy of the applicable portion of the map. JDF 298W(a) R5-15 APPLICATION FOR UNDERGROUND WATER RIGHT AND CERTIFICATE OF NOTICE Page 4 of 6© 2013, 2014, 2015 Colorado Judicial Department for use in the Courts of ColoradoB. If non-irrigation, describe purpose fully. Mark the location of proposed area of use on a USGS topographic map and attach to this application a legible 8 ½ x 11 inch copy of the applicable portion of the map.10. Name(s) and address(es) of owner(s) or reputed owners of the land upon which any new or existing diversion or storage structure, or modification to any existing diversion or storage structure is or will be constructed or upon which water is or will be stored, including any modification to the existing pool. The applicant must notify these persons that the applicant is applying for this water right, and certify to the Court that the applicant has done so by no later than 14 days after filing this application. The certification form is on page 5 of this form.Name of Owner Mailing Address11.Remarks:____________________________________________ ____________Signature of Applicant (if self-represented) or Attorney Date JDF 298W(a) R5-15 APPLICATION FOR UNDERGROUND WATER RIGHT AND CERTIFICATE OF NOTICE Page 5 of 6© 2013, 2014, 2015 Colorado Judicial Department for use in the Courts of Colorado VERIFICATION AND ACKNOWLEDGMENT OF APPLICANT OR OTHER PERSON HAVING KNOWLEDGE OF THE FACTS STATED IN THIS APPLICATION I ____________________________being first duly sworn, hereby state that I have read this Application, that I have personal knowledge of the facts stated and, that I verify its contents to the best of my knowledge, information, and belief. ____________________________________________ Signature Date The foregoing instrument was acknowledged before mein the County of ________________, State of Colorado, this ____day of ____________, 20___, by the person whose signature appears above. My Commission Expires: ________________ _____________________________________________ Notary Public/Deputy Clerk The person signing this verification is: Applicant Engineer Other (describe) ____________________Verifications of other persons with knowledge of the facts may be attached to this Application. JDF 298W(a) R5-15 APPLICATION FOR UNDERGROUND WATER RIGHT AND CERTIFICATE OF NOTICE Page 6 of 6© 2013, 2014, 2015 Colorado Judicial Department for use in the Courts of ColoradoDistrict Court, Water Division ___________________, Colorado Court Address:________________________________________________________ CONCERNING THE APPLICATION FOR WATER RIGHTS OFApplicant:In the ____________________________River or its TributariesIn ________________________________________ COUNTY COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E-mail:FAX Number: Atty. Reg. #:Case Number:Division: Courtroom: Certificate of Notice I, ________________________________________________ (insert name) hereby certify that I have provided a copy of the application filed on ____________________ (date) with the Court to the following owner(s) of the land upon which any new diversion or storage structure or modification to any existing diversion or storage structure or existing storage pool is or will be constructed or upon which water is or will be stored:1. ____________________________________________________________________________2.____________________________________________________________________________3.____________________________________________________________________________The application was provided to the landowner(s) by Certified or Registered mail, return receipt requested, within 14 days after the application was filed with the Court.Date: __________________________ _____________________________________ Signature/Title