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FORM U.W.5 Ly•00/r.c r\
FILINGRev.3.9FEE SCHEDULE STATE OF WYOMING TA
ON REVERSE SIDE OFFICE OF THE STATE ENGINEER
HERSCHLER BLDG.,4-E CHEYENNE,WYOMING 82002
APPLICATION FOR PERMIT TO APPROPRIATE GROUND WATER
APPLICATION FOR WELLS AND SPRINGS •
Note: Only springs flowing 25 gallons per minute or less,where the proposed use Is
domestic and/or stock watering,will be considered as ground water appropriations.
FOR OFFICE USE ONLY
Temporary Filing No.U.W. L&2 7-364.
PERMIT NO.U.W. 9 6 • 7 + NOTE:Do not told this form. Use typewriter or print neatly with
black ink.
WATER DIVISION NO. / DISTRICT /A, ALL ITEMS MUST BE COMPLETED BEFORE
U.W.DISTRICT Lara�Yde- Coy. ., /try APPLICATION IS ACCEPTABLE
NAME AND NUMBER OF WELL or SPRING /all?R /
1. Name of applicant(s) Sif/IR0Al 4P,g_i i_-/( Phone: $$�`o7-63S-07GS
2. Address of applicant(s)_ t0 BOX SU17Li 1 iY(Q 444 f12. W/ 2a..Oo 3
(STREET) (CITY) (STATE) (ZIP)
3. Name&address of agent to receive correspondence and notices Stifit.Q,
Phone:
(STREET) (CITY) (STATE) (ZIP)
4. Use to which the water will be applied:
❑ Domestic: Use of water in 3 single family dwellings or less,noncommercial.watering of lawns and gardens
totalling one acre or less. Number of houses served?
❑ Stock Watering: Normal livestock use at four tanks or less within one mile of well or spring. Stockwatering pipelines
and commercial feedlots are a miscellaneous use.
❑ Irrigation: Watering of commercially grown crops,(large-scale lawn watering of golf courses,cemeteries,
recreation areas,etc., is miscellaneous use.)
❑ Municipal: Use of water in incorporated Towns and Cities, (use of water in unincorporated towns,subdivisions,
improvement districts,mobile home parks,etc.are classified as miscellaneous use.)
❑ Industrial: Long term use of water for the manufacture of a product or production of oil/gas or other minerals,
(oil field water flood operations, power plant water supply,etc). (Describe in REMARKS)
Miscellaneous: Any use of water not defined under previous definitions such as stockwater pipelines,subdivisions,
mine dewatering, mineral/oil exploration drilling, reclamation purposes, potable and sanitary
supplies in offices or light manufacturing,animal waste management,etc. Describe miscellaneous
use completely: Sc . ge-Art. ,H
❑ Monitor,Observation or Test Well: (Describe In REMARKS)
5. Location of the well or spring: (NOTE: Quarter-quarter(40 acre subdivision) MUST be shown. EXAMPLE: SE 1/4 NW 1/4
of Sec.12,Township 14 North, Range 68 West.) CZ 07L /)
LA}arrf i 2 County, N E 1/4 NE 1/4 of Sec. a 1 ,T. 1 a N., R. 6 IoW.of the 6th P.M.(or W.R.M.),
Wyoming. If located in a platted subdivision,also provide Lot , Block of the
Subdivision (or Add'n)of . Resurvey Location: Tract ,(or Lot)
6. Estimated depth of the well or spring is 3o fl feet.
7. (a) MAXIMUM instantaneous flow of water to be developed and beneficially used: 2 S gallons per minute.
NOTE: If for domestic and/or stock use, this application will be processed for a maximum of 25 gallons per minute. For a
spring,after approval of this application,some type of artificial diversion or improvement must be constructed to qualify for a
water right.
(b) MAXIMUM volumetric quantity of water to be developed and beneficially used per calendar year: 5'O o_c. I4•
Circle appropriate units: (Gallons) t�cre Feet A four person family utilizes approximately one (1) ^•n t^^t nf water tier
year or 325,000 gallons. Wit C4
8.If use is not irrigation, mark the point(s) or area(s)of use in the tabulation box below.
well or spring is to be constructed on lands owned by
i'he granting of a permit does not constitute the granting of right-o-Nay. If any easement.or right-of-way is necessary in
,connection with this application, it should be understood that the responsibility is the applicant's. A copy of the agree-
ment should accompany this application, if the land is privately owned and the owner is not the co-applicant.)
2. The water is to be used on lands owned by ,rt /• f
(If the landowner is not the applicant,a copy of the agr a ent relating to the usage of appropriated water on the land
should be submitted to this office. If the landowner is included as co-applicant on the application, this procedure need
not be followed.) NOTE: Water rights attach to the area(s)and/or point(s)of use.
REMARKS: ,•es 6
'le •
Under penalties of perjury, I declare that I have examined this application and to the best of my knowledge and belief it is true,
correct and complete.
Signature of pplicant or Authorized Agent — / /6 , 19
Date
THE LEGALLY REQUIRED FILING FEE MUST ACCOMPANY THIS APPLICATION
DOMESTIC AND/OR STOCK WATERING USES
(Domestic use is defined as use of water in 3 single family dwellings or less, $25.00
noncommercial watering of lawns and gardens totalling one acre or less.)
IRRIGATION, MUNICIPAL, INDUSTRIAL,MISCELLANEOUS
$50.00
MONITOR (For water level measurements or chemical quality sampling,test well)
NO FEE
IF WELL WILL SERVE MULTIPLE USES,SUBMIT ONLY ONE(THE HIGHER)FILING FEE.
THIS SECTION IS NOT TO BE FILLED IN BY APPLICANT
THE STATE OF WYOMING )
NGINEER'S OFFICE ss.
instrument was received and filed for record on the 16th August
19 94 ,at 4:00 o'clock P. M. r
day of A D
Permit No. U.W. ____9_6274___________
fo to
THIS IS TO CERTIFY that I have examined the foregoing application and do hereby nt the same subject to the following
limitations and conditions:
This application is approved subject to the condition that the proposed use shall not interfere with any existing rights to ground
water from the same source of supply and is subject to regulation and correlation with surface water rights, if the ground and
surface waters are interconnected. The use of water hereunder is subject to the further provisions of Chapter 169,Session Laws
of Wyoming, 1957,and any subsequent amendments thereto.
Granting of a permit does not guarantee the right to have the water level or artesian pressure in the well maintained at any
specific level. The well should be constructed to a depth adequate to allow for the maximum development and beneficial use of
ground water in the source of supply.
If the well is a flowing artesian well,it shall be so constructed and equipped that the flow may be shut off when not in use without
loss of water into sub-surface formations or at the land surface.
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Approval of this application may be considered as authorization to proceed with construction of the proposed well or spring.
Construction of well or spring will begin within one(1)year from date of approval. A Statement of Completion will be filed within
thirty(30)days of completion of construction,including pump installation.
Completion of❑nnsfruellan',..a v,_,..,,.
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